Persius/imr-appeals huggingface dataset:
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:   An enrollee has requested magnetic resonance imaging (MRI) for evaluation of her medical condition.  Findings:  The physician reviewer found that in this patients case, an MRI is not medically necessary for evaluation of the patients medical condition. Medical literature supports obtaining an MRI in anticipation of some sort of intervention such as surgery or facet injections. Prior to an intervention, standard medical practice is to attempt a trial of conservative treatments such as physical therapy, a targeted exercise program, or methodical use of anti-inflammatory drugs. The submitted documentation does not support the use of an MRI, at this time. As stated by Roudsari and Jarvik, `All of the guidelines emphasize the importance of a focused history and thorough physical examination before any imaging is ordered. In addition, all agree that for patients with acute LBP [low back pain] and without any risk factor for serious spine abnormalities, imaging within the initial 48 weeks should not be performed.` Moreover, The American College of Radiology (ACR) has established appropriateness criteria for the evaluation of back pain. The ACR agrees that MRI is not warranted in the acute setting. In the setting of back pain in which the patient is a candidate for surgery or other intervention, the ACR considers an MRI to be the most appropriate study, with no stipulation about delaying the MRI. Thus, a strong recommendation against the routine use of MRI for chronic low back pain (CLBP) evaluation is made. Chou and colleagues make the specific recommendation that, There is insufficient evidence to support the routine use of MRI in patients with CLBP.  For the reasons stated above, the medical necessity of the requested MRI has not been established.  Final Result: The reviewer determined that the requested service is not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: The reviewer is board certified in diagnostic radiology 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: Overturned

Nature of Statutory Criteria/Case Summary: A patient has requested reimbursement for the endovenous ablation therapy, with transcatheter delivery of a chemical adhesive to the right small saphenous vein. Findings:  Two physician reviewers found that the decision to use VenaSeal versus an alternate technique for vein ablation is supported in the current peer-reviewed medical literature. As concluded by one study, VenaSeal cyanoacrylate closure is safe is safe and effective for the treatment of one or more incompetent saphenous or accessory saphenous vein. Similarly, another medical study found that use of cyanoacrylate closure is safe and effective. This patients Doppler study revealed no evidence of deep vein thrombosis, small saphenous reflux via the sapheno-popliteal junction and left small saphenous vein reflux. Considering the scientific data in support of the procedure performed in this clinical setting, the endovenous ablation therapy, with transcatheter delivery of a chemical adhesive to the right small saphenous vein was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.One reviewer found that the endovenous ablation therapy, with transcatheter delivery of a chemical adhesive to the right small saphenous vein was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: Two of the three 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:  One reviewer is board certified in surgery with subspecialty certification in general vascular surgery and is actively practicing. One Reviewer is board certified in surgery with subspecialty certification in general vascular surgery and is actively practicing.  One Reviewer is board certified in surgery with subspecialty certification in general vascular surgery 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: Experimental/Investigational
Decision: Overturned

A 30-year-old female enrollee has requested repetitive transcranial magnetic stimulation (TMS) services for treatment of her major depressive disorder. Findings:  Three physician reviewers found that the requested services are likely to be more effective for this patient than other available treatment options. In this case, the patient presents with a debilitating unilateral depressive disorder with a formidable affective symptom complex that is causing significant morbidity and functional impairment. Despite trialing appropriate psychotropic medications and augmentative strategies, and participation in evidence-based psychotherapies for depression, the patient remains symptomatic. TMS therapy is reasonably expected to improve her condition and prevent a more serious episode of illness. Furthermore, TMS is safe, appropriate and consistent with good medical practice.  Considering the case in its entirety within the context of the most current practice guidelines and relevant peer reviewed literature, repetitive TMS is likely to be more beneficial for treatment of the patients medical condition than any remaining available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned

The patients parent has requested authorization and coverage for speech therapy services once per week. The documentation provided for review supports that this patients diagnoses include autism spectrum disorder as well as speech and language delays. Despite oppositional or maladaptive behaviors present, this does not present an insurmountable obstacle to achieving benefits for the development of speech and language with services once per week. The provider noted that the patient has demonstrated some negative behaviors, which interfere with interactions and intervention. However, the patient has made progress since starting speech and language therapy services and he responded well to positive reinforcements to keep him engaged. Given these findings, the requested speech therapy services once per week is medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in neurology with special qualification in child neurology 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: Medical Necessity
Decision: Upheld

A 58-year-old female enrollee has requested Lyrica for the treatment of her lumbar stenosis. Findings:  The physician reviewer found that the indications for Lyrica include neuropathic pain associated with diabetic peripheral neuropathy, postherpetic neuralgia, as an adjunct therapy for adult patients with partial onset seizures, as well as fibromyalgia. Lyrica is not recommended for lumbar spinal stenosis.  There are no studies of Lyrica in spinal stenosis. One group recently attempted to stratify medications used for all types of neuropathic pain. They looked at 105 studies of various medications used to treat neuropathic pain and found that in general, tricyclic antidepressants had the highest efficacy, followed by opioids, and finally pregabalin (Lyrica). In this patient, there is no documentation of trials of other medications that could be used for general neuropathic pain, including tricyclic antidepressants. The requested medication is not medically indicated for treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for heartburn surgery. Findings:  Three physician reviewers found that the efficacy of TIF has been demonstrated by randomized controlled trials. However, the data is contradictory. One large randomized trial including 60 patients found no improvement in esophageal acid exposure compared with baseline at 12 months; normalization of pH was accomplished in only 29% in conjunction with deteriorated valve appearances at endoscopy and resumption of PPIs in 61%. The study concluded that no long-term objective reflux control was achieved.  The American College of Gastroenterology guidelines for treatment of GERD report that the usage of current endoscopic therapy or TIF cannot be recommended as an alternative to medical or traditional surgical therapy (moderate level of evidence). The Society of American Gastrointestinal and Endoscopic Surgeons reported that numerous published series have reported significant adverse events and that there is a lack of sham-controlled trials comparing TIF with anti-reflux surgery. Studies concluded that further studies are required to define optimal techniques and most appropriate patient selection criteria, and to further evaluate device and technique safety. These conclusions are bolstered by recent reports of severe adverse events during the procedure and the need for surgery to revise ineffective TIF. Furthermore, high-quality clinical trial data in patients with prior Nissen fundoplication are limited. For these reasons, the requested transoral incisionless fundoplication along with anesthesia to tighten the wrap is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: 3 of 3 reviewers determined that the requested surgery 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: All three physician reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology 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: Overturned

A 49-year-old male enrollee requested authorization and coverage of continued chiropractic care. The Health Plan  denied the request indicating that the requested therapy is not medically necessary for the treatment of the enrollees back pain.One chiropractor reviewer performed a medical necessity Independent Medical Review. The chiropractor reviewer overturned the Health Plans denial on the basis that the requested therapy is medically necessary.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:An enrollee has reimbursement for gene panel testing for evaluation of the enrollee who presented for prenatal care. Findings:  The physician reviewer found that The American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine recommends cell free DNA testing as a screening option for women at increased risk of fetal aneuploidy. This population was defined as women 35 years or older, fetuses with ultrasonographic findings indicative of an increased risk of aneuploidy, women with a history of trisomy-affected offspring, a parent carrying a balanced Robertsonian translocation with an increased risk of trisomy 13 or trisomy 21, and women with positive first-trimester or second-trimester screening test results. Since this patient is older than 35 years old, the aneuploidy risk for this patient, in this pregnancy, warrants cell free DNA testing for aneuploidy including monosomy X. For these reasons, the gene test performed was likely to have been of greater benefit in evaluating this patients medical condition than the available standard therapy. Final Result: Three 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: Physician reviewer number one is board certified in obstetrics and gynecology 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.Physician reviewer number two is board certified in obstetrics and gynecology 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.Physician reviewer number three is board certified in obstetrics and gynecology 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: Medical Necessity
Decision: Upheld

A 20-year-old male enrollee has requested transcranial magnetic stimulation (TMS) for treatment of his major depressive disorder.  Findings:  The physician reviewer found the submitted documentation fails to demonstrate the medical necessity of the services at issue. TMS therapy is not clinically indicated unless there is a lack of response to adequate trials of psychotherapy and pharmacotherapy. Details regarding the patients prior psychotherapy were not provided, and the records do not demonstrate that pharmacotherapy options were exhausted. Further, having failed a course of electroconvulsive treatments, the patient was not likely to have a positive response to transcranial magnetic stimulation. Per the current medical literature, transcranial magnetic stimulation is not as efficacious for treatment-resistant or refractory depression as electroconvulsive therapy.  All told, transcranial magnetic stimulation (TMS) is not medically necessary.
Appeal type: Experimental/Investigational
Decision: Overturned

A 55-year-old male enrollee has requested 15 tablets of 100mg Viagra monthly for the treatment of the enrollee, who is status post radical prostatectomy. Findings:  Two physician reviewers found that this patient has undergone robotic-assisted radical retropubic nerve-sparing prostatectomy for moderately differentiated prostate cancer. He has requested authorization for the therapeutic use of sildenafil postoperatively to assist in the return of potency, despite the fact that a nerve sparing technique was utilized during the procedure. The Health Plan has denied coverage for 15 tablets of 100mg Viagra monthly, and this is the subject of the appeal. Postoperative PDE5 inhibitor therapy is used to hasten revascularization as well as to deter the possibility of fibrosis of the corpora cavernosa. This recommendation is routinely endorsed by the urologic community. A review of the current literature offers substantiation as to the efficacy of this approach. It is particularly useful in the younger patient, irrespective of whether nerve sparing was performed or not. It should be noted that sildenafil use for resurrection of potency is not an open-ended commitment and is usually administered over a finite period of time, approximating one to two years.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: A enrollee has requested authorization and coverage for left total hip replacement. Findings:  The physician reviewer found that Osteoarthritis is a degenerative condition that commonly affects knees and hips. The treatment depends upon the severity of the subjective complaints such as severe groin pain with ambulation and nocturnal pain that is refractory to conservative measures, the objective findings of diminished range of motion with impairment of function, and radiographic findings of joint space narrowing, all of which are present in this case. The recommended total hip arthroplasty has a predictable result and has been shown to improve a patients physical and psychological well-being. Based on the history, physical findings, and imaging studies, the patient meets the indications for a total hip arthroplasty and is a good candidate for the same. Any additional physical therapy is not likely to relieve his pain or significantly alter the need for a total hip arthroplasty. Therefore, the requested left total hip replacement is medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in orthopedic surgery 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: Medical Necessity
Decision: Overturned

The enrollee is requesting reimbursement for partial hospitalization program (PHP) level of care services and intensive outpatient program (IOP) level of care services. The enrollee has a history of opioid use, beginning at age 18 after wisdom tooth extraction and ankle surgery. He also reported current heroin use (smoking), daily cannabis use since age 15; sedative use, i.e., 2 milligram of Xanax four times per day; and Norco use since shoulder surgery. The enrollee reported he would use heroin for two weeks, stop due to finances, and experience withdrawal symptoms. He reported a long-standing history of severe anxiety and a sleep pattern of one to two hours per night. The enrollee stated he experienced heart palpitations and sweating due to drug use. He reported a history of depression and five suicide attempts between the ages of 17 and 21. The recommendation was for admission to the partial hospitalization program, with a transition to an intensive outpatient program. The enrollee entered treatment. He developed an understanding of the causes of his anxiety and worked to identify three positive emotions he would like to experience on a daily basis. He developed an understanding about how thoughts, feelings and behaviors are connected. He learned to identify maladaptive, negative thoughts and how to replace them with positive, adaptive thoughts. He used smart recovery coping skills to manage and engage in at least two positive daily activities that promote growth and success. The Level of Care Utilization System (LOCUS), developed by the American Association of Community Psychiatrists, is a level of care assessment tool widely used by clinicians throughout the country to support accurate level of care recommendations. The six dimensions of LOCUS include risk of harm, functional status, comorbidity, recovery environment, level of support, and treatment and recovery history. The enrollees composite LOCUS score correlates with low intensity, community-based services; which can be either a partial hospitalization program or an intensive outpatient program.Final Result: The reviewer determined that the requested services were medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in psychiatry 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Epclusa for 12 weeks for treatment of the enrollees hepatitis C. Findings:  The physician reviewer found that the physician reviewer found that according to joint guidelines issued by the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America, all patients with chronic hepatitis C should be treated except those with life expectancy less than 12 months due to non-liver-related conditions. This applies regardless of fibrosis stage, and advanced fibrosis is not required for treatment. Per the guidelines, Epclusa is recommended as first-line therapy for treatment-naive, genotype 2 patients.  A delay in treatment may result in decreased survival. For these reasons, Epclusa for 12 weeks is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medication regimen is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology 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: Overturned

A 51-year-old male enrollee has requested authorization and coverage for chemotherapy with Vectibix.  The Health Plan has denied this request indicating that the requested medication is considered investigational for treatment of the enrollees stage IV colon cancer with liver metastasis.  Findings:  Three physician reviewers found that the patient is status post hemicolectomy.  He received Avastin/FOLFOX and Avastin/FOLFIRI.  The patients tumor has wild type K-RAS sequence.  He has also been treated with cetuximab.  He has requested authorization and coverage for chemotherapy with Vectibix.  The Health Plan has denied this request and reported that Vectibix is investigational for the treatment of this patient.  In this patients case, the requested medication is likely to be superior over other available treatment options.  Vectibix (panitumumab) is approved for use in metastatic colon cancer that has progressed through 5-FU or oxaliplatin chemotherapy.  There is no mention on the label regarding cetuximab prior therapy.  Both drugs are monoclonal antibodies that target the epithelial growth factor (EGFR) and appear to have similar mechanisms of action.  Additionally, both have shown efficacy in clinical trials.  The study by Metges and colleagues directly tested whether patients that had progressed on cetuximab would benefit with panitumumab. The studys preliminary results demonstrate a benefit for panitumumab in this setting.  There is sufficient evidence supporting the use of panitumumab in this patients case.  In sum, the requested chemotherapy with Vectibix is likely to be of greater benefit than other available treatment options.