Persius/imr-appeals huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for genetic testing for breast and ovarian cancer risk. Panel testing is considered the standard of care in this clinical setting. This patient meets the National Comprehensive Cancer Network (NCCN) criteria for genetic testing based on her family history. She is at risk to carry a BRCA1 or BRCA2 mutation or a variety of other mutations. Genetic testing is reasonable to evaluate her risk and establish strategies to decrease her risk of a second malignancy should she be shown to harbor an inherited mutation. Therefore, genetic testing for breast and ovarian cancer risk is likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: Two of the three reviewers determined that the requested services are likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: One reviewer is board certified in internal medicine with subspecialty certifications in medical oncology and hematology and is actively practicing. One reviewer is board certified in internal medicine with subspecialty certification in medical oncology and is actively practicing. One reviewer is board certified in internal medicine with subspecialty certification in medical oncology and is actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The mother of a four-year-old male enrollee requested authorization and coverage of continued speech therapy. The Health Plan denied the request indicating that the requested therapy is not medically necessary for treatment of the enrollees autism.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plans denial on the basis that the requested therapy is medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

A 47-year-old female enrollee has requested physical therapy and occupational therapy for the treatment of her carpal tunnel syndrome. Findings:  The physician reviewer found that the therapy provided for treatment of carpal tunnel syndrome was medically indicated. This treatment was prescribed by a physician to relieve pain, to improve strength/range of motion in the affected body part and to improve functional status. In my opinion, these objectives were achieved to a good extent. Occupational therapy was provided for right carpal tunnel syndrome. The treatment provided was standard and widely accepted for treatment of this condition. Treatment on the date in question was not prescribed by a physician, and the diagnosis of DeQuervains syndrome does not appear to have been diagnosed by a physician. Hence, therapy from the date in question and ongoing was not medically indicated.
Appeal type: Medical Necessity
Decision: Overturned

The patients parents indicate the patient has been followed for asthma since 1994. The patient was seen by her provider in January 2002 and treated with multiple medications. The patient was signed up for a research study and provided with Foradil samples. The study was discontinued. In addition to treatment for asthma, the patient is receiving allergy injections prescribed by another provider. The patients parent indicates the patient was still having trouble with asthma and was using albuterol puffs more often than recommended, especially when exercising. The patients physician has indicated that the formulary equivalent, Serevent, has possible dangerous side effects A request has been made for authorization and coverage for Foradil, which has been denied by the Health Plan.Review of the submitted information indicates the patient has a documented history of urticaria and asthma, including exercise-induced symptoms.  The patient is involved in competitive long distance running. Although studies have indicated the danger of side effects for Serevent without the concurrent use of inhaled corticosteroid, the drug Foradil has the same potential for risk without the concurrent use of inhaled corticosteroid. However, studies have demonstrated the long-acting bronchodilator, Foradil has a more rapid onset of action and longer duration of action in the treatment of asthma. In addition, studies have demonstrated a greater improvement in airway resistance as compared to Severent.Therefore, in light of the advantages of Foradil, I have determined it is medically necessary for control of the patients exercise-induced asthma. As such, the Health Plans denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Overturned

An enrollee has requested reimbursement for hip arthroscopy with femoroplasty. This patient presented with a history of right hip pain. On physical examination, the patients pain was associated with tenderness and some restriction of motion, particularly abduction and internal rotation. X-rays revealed 1 mm narrowing of the right hip joint space compared to the left. Magnetic resonance arthrogram demonstrated hypertrophic labrum, subchondral cyst formation in the acetabulum, and denting of the head and neck junction, indicating cam and pincer impingement. The patient underwent a complex right hip arthroscopy. Femoroacetabular impingement is a clinical syndrome, characterized by abnormal cam or pincer type morphology in the hip that alters the biomechanical, forces causing rapid progression of osteoarthritis and chondral and labral tearing. Early arthroscopic surgical intervention can provide symptomatic relief and delay the onset of osteoarthritis. Imaging findings of femoroacetabular impingement are oftentimes subtle, as in this case. Surgery was appropriate due to persistent pain, functional limitations, and lack of response to conservative treatment. In light of the foregoing, the hip arthroscopy with femoroplasty was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Findings:  Three of the three physician reviewers found the hip arthroscopy with femoroplasty was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the services at issue were likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewers 1, 2, and 3 are board certified in orthopedic surgery and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

A 61-year-old male enrollee has requested stereotactic body radiotherapy (SBRT) or intensity modulated radiation therapy (IMRT) for treatment of his pancreatic cancer. Findings:  Three physician reviewers found that based on the medical records reviewed the use of either SBRT or IMRT in this setting is clinically indicated and likely to be more beneficial for treatment of the patients medical condition. There have been a multitude of clinical studies regarding the use of SBRT for pancreatic cancer which have demonstrated improved local control with slightly increased, but reasonable toxicity. Thus, the decreased number of fractions with SBRT has the advantage of improved local control. Furthermore, dose to critical structures, such as bowel, kidneys and liver, is improved with IMRT, which in turn translates to less toxicity (Van der Geld, et al). The advantage of IMRT is decreased toxicity with the disadvantage of increased length of treatment course. Thus, the decision of the two modalities should be at the discretion of the treating provider and patient, with consideration of tolerance of side effect and patient factors.
Appeal type: Medical Necessity
Decision: Upheld

A 57-year-old male enrollee has requested Intermezzo for treatment of his insomnia.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication in this patients case.  This patient has been diagnosed with insomnia.  Intermezzo is a non-benzodiazepine hypnotic.  These medications have less overall risk of adverse effects but still may cause impaired memory and psychomotor retardation.  Non-benzodiazepine hypnotics used for the treatment of insomnia include zolpidem (Ambien), Intermezzo, zaleplon (Sonata), and eszopiclone (Lunesta).  The Health Plan indicates that generic zolpidem and Lunesta are the preferred drugs for the treatment of insomnia in the non-benzodiazepine class.  Per the medical records, this patient has not tried and failed the preferred medications.  The Health Plans formulary medications are medically appropriate in this clinical setting.  All told, Intermezzo is not medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

A 59-year-old female enrollee has requested hormone pellet implants for treatment of her symptomatic menopause.  Findings:  Three physician reviewers found that the use of testosterone therapy in women is not standard of care. Some medical literature suggests that for postmenopausal women with hypoactive sexual desire disorder in whom non-pharmacologic therapy has been unsuccessful, a trial of testosterone is reasonable. This patient has symptoms of hypoactive sexual desire disorder. She has been treated with testosterone cream and still has symptoms. Based on the available peer-reviewed medical literature, there is inadequate data that hormone pellet implants are more safe or effective than standard available forms of testosterone. Therefore, the hormone pellet implants at issue were not and are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Urgent Care
Decision: Upheld

A 32-year-old male enrollee has requested emergency services for the treatment of his condition. Findings:  The physician reviewer found that the patient was suffering from an early flare up of a chronic condition. At the time of presentation to the emergency department, he was not suffering from significant pain, and he had no fever. According to the patient, he was being followed by several physicians for this condition. It seems reasonable that he could have contacted one or more of these physicians regarding the current flare up. As this patient was not suffering from severe pain, and there did not appear to be any threat to his life or bodily organ functions, a prudent layperson would not be expected to seek immediate emergency medical evaluation.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested breast tomosynthesis for evaluation of her medical condition. Findings:  Two physician reviewers found that the addition of breast tomosynthesis to routine screening has gained worldwide popularity among radiologists due to an associated decrease in callbacks and increase in detection of small cancers.  The added benefit occurs due to the ability of radiologists to separate glandular overlying tissue from underlying architectural distortion or mass which in turn improves reader confidence.  Thus, the addition of breast tomosynthesis to the usual screening films was likely to have been of greater benefit to the patient than digital screening mammography without tomosynthesis.Final Result: Two reviewers determined that the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: All three reviewers are board certified in diagnostic radiology and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 37-year-old male enrollee has requested a continuous passive motion device for treatment of his torn right anterior cruciate ligament. Findings:  The physician reviewer found that controversy remains regarding the use of continuous passive motion devices in knee rehabilitation following anterior cruciate ligament reconstruction, as noted by Bach. Although some studies indicate less pain in the immediate postoperative period (i.e., while the patient is in postoperative recovery), there are conflicting reports of the results of continuous passive motion device beyond immediate use. In one study, six months after surgery, the patients using the continuous passive motion device showed no significant difference in range of motion compared to those not using a continuous passive motion device. After two years following surgery, both groups had similar findings, as noted by Beynnon and colleagues. All told, there is a lack of evidence showing that the at-home use of a continuous passive motion device results in improved outcomes in this setting.
Appeal type: Experimental/Investigational
Decision: Overturned

A 38-year-old male has requested electrical muscle treatment (WalkAide) for treatment of his right-sided weakness, spasticity and incoordination.  Findings:  The physician reviewer found that the patient suffered multiple injuries in a motorcycle accident.  The medical records noted a cervical spine injury.  As a result, the patient has spasticity of his leg and arm and right-sided hemiparesis, including a foot drop.  He has fallen secondary to his lower extremity dysfunction.  Given his gait impairment, the patients physician has recommended electrical muscle treatment (WalkAide).  Although a WalkAide is not indicated for all patients with a foot drop, there is medical literature supporting its use for a select population of patients.   The medical literature has demonstrated the safety and efficacy of this type of therapy for patients with chronic upper motor neuron disease.  Daly and colleagues showed that a neuromuscular stimulation device improved gait component execution and knee flexion coordination compared to controls who did not receive the stimulation device. Mesci and colleagues showed that spasticity decreased and dorsiflexion increased in a functional electrical stimulation group compared to controls during a single-blind randomized trial. In this particular case, the patient has foot drop and gait impairment secondary to his cervical spinal cord injury.  Given the provided literature and the fact that the patient had a suboptimal response to a brace and cane, the WalkAide is likely to be more beneficial compared to standard treatments.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary:The patient has requested authorization and coverage for thermal radiofrequency ablation (RFA) of the nerves in the sacroiliac (SI) joint, also known as Sinergy. Findings:  The physician reviewer found that Sacroiliac (SI) joint pain is a well-documented syndrome, which can generally involve infection, malignancy, pregnancy, and acute or repetitive trauma. Symptoms include low back, buttock and thigh pain and sometimes sciatic-like radiating pain. Along with conservative measures like anti-inflammatories, heat, ice and some manipulation, SI joint injections have shown some merit in regards to fluoroscopic guidance with local and steroid with inter-articular placement of the medication. In a study, radiofrequency neurotomy was reviewed noting limited evidence. The author cited variability with nerve patterns studied as well as variations in electrode positioning with many of the studies. Hansen and colleagues reported that controlled double confirmative blocks with a long acting and short acting local anesthetic was found to be the gold standard for diagnosis of SI joint pain. In light of the current reviews, the requested radiofrequency ablation (RFA) of the nerves in the SI joint, also known as Sinergy, is not likely to be more beneficial for treatment of this patients medical condition than any available standard therapy. Final Result: Two of the three reviewers determined that the requested service is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewers are board certified in anesthesiology with sub-specialty certification in pain medicine and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for residential treatment center (RTC) services for treatment of the enrollees alcohol abuse and bulimia. Findings:  The physician reviewer found that based on the records provided for review, the RTC services provided were not and are not medically necessary for treatment of this patients medical condition. The patient denied suicidal or homicidal ideation, and she was not self-harming. She had gained 7.3 pounds, placing her at 92% of her ideal body weight (IBW) and had a BMI of 20.5. She had eating disorder urges but did not show any behaviors. She required supplementation, but her compliance and intake were high. Her gastrointestinal symptoms, medications, and continued substance abuse recovery did not require treatment at the RTC level of care. Her eating disorder no longer required 24-hour medical and nursing supervision. She could have been stepped down to an ambulatory level of care such as partial hospitalization program (PHP). Thus, the services at issue were not and are not medically necessary. Final Result: The reviewer determined that the services at issue were not and are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in psychiatry with sub-specialty certification in addiction medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 62-year-old male has requested coverage for past and future transcranial magnetic stimulation and maintenance every two months or as needed for treatment of his mental health conditions.   Findings:  Three physician reviewers found that the patient has a history of mood and anxiety symptoms.  Per the medical records, he has a history of alcohol dependency and was reportedly in remission.  Last year, his treating psychiatrist noted the diagnosis of bipolar disorder.  His symptom complex consisted of low energy, anhedonia, depressed and sad mood, feelings of worthlessness, excessive pessimism, hypersomnia, and suicidal ideation.  The patient had trialed multiple medications, including Remeron, Paxil, Cymbalta, Lexapro, Wellbutrin, Lamictal, Depakote, Strattera, Klonopin, propranolol, Provigil, topiramate, Ritalin, Concerta, Adderall, and Vyvanse.  As noted by the provider, psychopharmacotherapy has not achieved remission.    The superior efficacy of transcranial magnetic stimulation has not been established in this patients case.  The patient was diagnosed with bipolar disorder.  There is a lack of well-controlled and adequately powered exploratory and confirmatory studies supporting the use of transcranial magnetic stimulation for patients with this condition.  Therapeutically, there was no mention of intermediate treatment settings, such as intensive outpatient or partial hospitalization programming.  This patient has trialed multiple medications, but he has not exhausted commonly utilized augmentative strategies, such as lithium, buspirone, thyroid hormone, quetiapine, or aripiprazole.  Further, he has not trialed antidepressants from alternative classes.  Finally, there is no reported contraindication to electroconvulsive therapy.  Electroconvulsive therapy remains the proven non-pharmacologic intervention to which other stimulatory techniques are measured.  There is a lack of well-designed studies demonstrating the superior effectiveness of transcranial magnetic stimulation as compared to electroconvulsive therapy.
Appeal type: Experimental/Investigational
Decision: Upheld

A 44-year-old male enrollee has requested transcranial magnetic stimulation therapy for treatment of his major depression. Findings:  Two physician reviewers found that although the safety of transcranial magnetic stimulation has generally been established, its efficacy has not been documented for this clinical situation. The medical literature indicates that transcranial magnetic stimulation has been shown to be effective in those patients who have not responded to a single antidepressive agent. This patients clinical course, as described in the medical records, does not clearly demonstrate that this patient was not responsive to pharmacotherapy with or without more conventional adjunctive treatment. Furthermore, even if the patient derived no benefit from antidepressant medication, according to the FDA approval for transcranial magnetic stimulation, its efficacy has not been established in patients who have failed to receive benefit from two or more prior antidepressant treatments. As such, there is inadequate scientific evidence to support the efficacy of transcranial magnetic stimulation in this particular setting.