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

A 43-year-old male enrollee has requested residential treatment services for treatment of his alcohol dependence. Findings:  The physician reviewer found that based on review of the available records, this patient meets the continued stay criteria for residential services provided from the timeframe indicated. According to the American Society of Addiction Medicine (ASAM) guidelines for inpatient rehabilitation services for substance abuse, continued stay is appropriate if the patient identifies with the severity of the alcohol problem and manifests insight, yet does not demonstrate behaviors suggestive that he has developed the problem solving skills necessary to cope with the problem and would likely relapse if transitioned to a lesser level of care. The records demonstrate that this patient remained at high risk for relapse although he had made some progress toward identification of the severity of his alcohol problem.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for the bilateral total capsulectomy and breast implant removal. Cohen Tervaert and colleagues state, Autoimmune/inflammatory syndrome by adjuvants (ASIA), allergies, autoimmune diseases, immune deficiencies and lymphomas occur in patients with silicone breast implants. Findings:  The physician reviewer found that the is a need for adequately adjusted epidemiological studies to ascertain the frequency of these diseases. Balk and colleagues conclude, The evidence remains inconclusive about any association between silicone gel implants and long-term health outcomes. Chao and colleagues report, Breast implant surgery is one of the most commonly performed procedures in the field of plastic surgery. While silicone implants are now routinely used in breast surgery, they have previously been the subject of controversy. This was particularly true in the U.S., where there was a moratorium on their use from 1992 to 2006. Following subsequent scientific validation of their safety, silicone implants have re-gained widespread acceptance for clinical use. Overall, silicone breast implants are associated with a high degree of patient satisfaction and low rates of complications. Further independent research is necessary to better establish long-term outcomes. In this case, the patient reports generalized complaints in the setting of silicone gel implants. However, given that the association of the patients complaints with the presence of silicone gel implants is speculative and cannot be confirmed, the service at issue was not medically indicated. Therefore, bilateral total capsulectomy and breast implant removal were not medically necessary for the treatment of this patient.The California reconstructive surgery statute requires health insurers to cover reconstructive surgeries, defined as surgery performed to correct or repair abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease to do either of the following: (1) to improve function; or (2) to create a normal appearance, to the extent possible. In this case, the presence of a cosmetic implant, in the absence of adjacent native tissue structural pathology, does not constitute an abnormal structure of the body. Accordingly, bilateral total capsulectomy and breast implant removal were not reconstructive in nature for the treatment of this patient.Final Result: The reviewer determined that the services at issue were 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 plastic 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: Experimental/Investigational
Decision: Overturned

A 59-year-old male enrollee requested authorization and coverage of chemoembolization.  The Health Plan denied the request indicating that the requested therapy is considered experimental for treatment of the enrollees metastatic carcinoid cancer.Three physician reviewers performed an experimental/investigational Independent Medical Review. All three physician reviewers concluded that the requested therapy is likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy. Because all three physician reviewers concluded that the requested therapy is likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy, the Health Plans denial has been overturned.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: A female enrollee has requested authorization and coverage for metformin ER 1000 mg. A study found some formulations of extended release metformin preparations have been demonstrated to have more tolerability compared to immediate release preparation. The patient has tried and failed the immediate release metformin in the past. However, there is no documentation to support that the patient has tried and failed metformin extended release (Glucophage XR) preparation which is a formulary alternative. Thus, the requested metformin ER 1000 mg is not supported as medically necessary for treatment of this patients type 2 diabetes. Final Result: The reviewer determined that the requested medication is 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 internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism 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:   An enrollee has requested dopamine transporter imaging with single photon emission computed tomography (DAT-SPECT) for evaluation of his medical condition.  Findings:  Two physician reviewers found that DAT-SPECT has utility in complex cases in differentiating between Lewy body dementia, essential tremor, and dementias.  In this particular case, the patient had a family history of Lewy body dementia and a history and examination notable for cognitive decline, a tremor, and some features of Parkinsons disease.  One clear etiology was not present by the patients history and examination.  In such cases, it is reasonable to obtain ancillary tests to help obtain an accurate diagnosis.  This limits trials of non-beneficial medications and potential side effects.  The lack of a proper diagnosis can lead to mismanagement of functional decline of a patient.  Therefore, DAT-SPECT was likely to have been superior over other methods of evaluating this patient. 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 neurology 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

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Xiaflex for treatment of his Peyronies disease.    The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication.  This patient has been diagnosed with Peyronies disease.  Intralesional injection therapies for patients with Peyronies disease seek to reduce plaque production, contracture, and improve on recurrence rate and progression.  However, at this time, the most effective treatment is surgery.  While there is data suggesting intralesional injection with Xiaflex may be beneficial, the findings are preliminary and further investigation is necessary to confirm long-term efficacy.  As noted in a study by Egui Rojo and colleagues, although Xiaflex has been approved by the U.S. Food and Drug Administration for the treatment of Peyronies disease, the long-term effects and results need further investigation, with large follow-up series. The current medical evidence has not demonstrated the long-term efficacy of Xiaflex in this clinical setting, and complications from injection may limit repeat treatments.  Therefore, Xiaflex is not medically necessary for the treatment of this patient.  Final Result: The reviewer determined that the requested medication is 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 urology 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 29-year-old male enrollee has requested radiofrequency ablation for treatment of his Barretts esophagus. Findings:  Two physician reviewers found that the requested services are not likely to be of greater benefit than other treatment options.  This patient has been diagnosed with Barretts esophagus.  Biopsies have been performed, and pathology results do not indicate dysplasia.  Given that there is no evidence of dysplasia, the current medical evidence does not support the requested radiofrequency ablation in this clinical setting.  The medical evidence supports surveillance in this patients case.  All told, the requested radiofrequency ablation is not likely to be more efficacious than other modalities for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

A male enrollee requested radiofrequency neurolysis for medical treatment of his pain. Findings:  Two physician reviewers found that the services at issue were not likely to be of greater benefit than other treatment options.  According to the peer-reviewed literature, further standardization of radiofrequency ablation of lesion techniques needs to be established, coupled with prospective randomized controlled trials.  Primary conservative treatment for sacroiliac joint pain includes rest, ice therapy, heat therapy, massage, medication, and injections.  All told, radiofrequency neurolysis was not likely to be superior over other treatment modalities.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Synvisc injections in both knees. Evidence from systematic reviews and randomized controlled trials indicate that although viscosupplementation may relieve knee pain in some patients with osteoarthritis, data has not established which patients will benefit. Guidelines from the American Academy of Orthopedic Surgeons (AAOS) indicate that data on the safety and efficacy of viscosupplementation remain inconclusive. As such, the AAOS does not currently recommend viscosupplementation as standard treatment for osteoarthritis of the knees. Viscosupplementation is reserved for patients with a history of lasting benefit from prior injections and in cases where the remaining options are limited. In this case, the patients remaining treatment options are limited. Moreover, the patient has a history of substantial benefit from prior viscosupplementation and she has tried and failed conservative therapies. All told, the requested Synvisc One injections in both knees are 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 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: Experimental/Investigational
Decision: Overturned

A 55-year-old male enrollee requested authorization and coverage of thalidomide for the treatment of renal cancer that has metastasized to the lung.  The health plan denied the enrollees request indicating that thalidomide is considered experimental.Three physician reviewers performed an experimental/investigational Independent Medical Review.  Two physician reviewers concluded that the requested thalidomide is likely to be more beneficial for treatment of the enrollees cancer than any available standard therapy.  Because two of the three physician reviewers concluded that the requested treatment is likely to be more beneficial for treatment of the enrollees medical condition than any available standard therapy, the review organization overturned the health plans denial.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for DecisionDx-Melanoma assay. The Health Plan has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees malignant melanoma.Findings:  There is a lack of support for the superior efficacy of the services at issue in this clinical setting. DecisionDx-Melanoma test claims to determine risk of recurrence for early melanoma, as in this patients case who is diagnosed with stage 1a. However, there is a lack of data to support using immunotherapy in early stage melanoma regardless of the recurrence risk. Furthermore, prospective randomized data for determination of recurrence risk is lacking for this test.  In sum, DecisionDx-Melanoma test was not likely to have been superior over the other standard modalities of evaluating this patients medical condition. Final Result: All three reviewers determined the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications:  All three reviewers are board certified in internal medicine with sub-specialty certification in medical oncology 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: Overturned

A 56-year-old female enrollee requested authorization and coverage of 18 Amerge 2.5mg tablets per month. The Health Plan denied the request indicating that the requested prescription is not medically necessary for treatment of the enrollees migraine headaches.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plans denial on the basis that the requested prescription is medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

A patient has a medical history that is significant for primary ciliary dyskinesia with bronchiectasis. At issue in this case is whether the requested high frequency chest wall oscillation system (SmartVest Airway Clearance System) is medically necessary for treatment of the patients medical condition. High frequency chest wall oscillation was developed to improve airway clearance in patients when the normal mucociliary transport system has failed, as with bronchiectasis. In this case, the patient has been compliant with all recommended interventions. She was initially prescribed an Aerobika for airway clearance, and despite routine frequent use, her pulmonary function declined and she remained symptomatic. The provider initiated vest therapy, with improvement in clinical symptoms, and no further decline in pulmonary function testing.Final Result: The reviewer determined that the requested device 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 pediatrics with subspecialty certification in pediatric critical care 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: Medical Necessity
Decision: Upheld

A 44-year-old male enrollee has requested Norco 10/325 (three times per day) for treatment of his small fiber peripheral neuropathy.  Findings:  The physician reviewer found that the requested Norco 10/325 (three times per day) is not medically necessary for management of this patients small fiber peripheral neuropathy. The current standard of care for chronic pain associated with peripheral neuropathy is treatment in a multidisciplinary practice to include physical therapy, massage therapy, behavioral therapy, and injections to help reduce pain. There are a variety of anti-convulsant and anti-depressant medications considered adjunctive to this therapy. Short release and short acting opioids are associated with a high risk of dependence and tolerance. For these reasons, long-term administration is not recommended (Fishman). In the medical literature, Baron and McDonald reported that high dose and short acting opiates might contribute to pain sensitization via opioid-induced hyperalgesia, decreasing patient pain threshold and potentially masking resolution of a pre-existing pain condition. In this retrospective study, the majority of patients undergoing detoxification of high dose opiates for chronic pain reported a significant decrease in pain at the end of the study, further supporting the theory of opioid-induced hyperalgesia. Therefore, it is in the patients best interest to wean off Norco. In addition, short acting opiates are more likely to cause adverse outcomes. Ballantyne and Mao reported that prolonged use of high dose, short acting opiates might induce tolerance, and abnormal pain sensitivity. The aim of current guidelines is to protect patients from the adverse effects of opioid therapy. Consistent with these findings, the requested Norco 10/325 (three times per day) is not medically necessary for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

A sixty-four year-old male with chest pain is requesting reimbursement for CT angiography.Reviewers FindingsAfter reviewing the request, 2 of the 3 reviewing physicians found that the CT angiography was likely to be more beneficial for evaluation of the patients medical condition.  The third physician found that a CT angiography would not be able to accurately confirm or exclude important coronary obstruction.  The reviewing physicians found that the Health Plan denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 45-year-old female who has idiopathic hypersomnolence. She has undergone a sleep study and was found to have mild sleep apnea. The sleep study also showed decreased sleep onset latency, but the patient does not have narcolepsy. The patient is not receiving other therapy for sleep apnea. The patients request for authorization of Provigil was denied by the Health Plan citing a lack of medical necessity.FDA approved indications for prescription of Provigil include narcolepsy, shift work sleep disorder and adjunctive therapy for sleep apnea. The patient has only mild sleep apnea and there is no peer-reviewed data to support the use of Provigil for the treatment of idiopathic hypersomnolence. The record indicates the patient is taking several other medications; some known to have a sedating effect. A review of current prescriptions with her provider may help to identify the source of her excessive daytime sleepiness. For these reasons, I have determined the requested medication is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a nine-year-old male enrollee has requested speech and occupational therapy services for the treatment of the enrollees autism. Findings:  The physician reviewer found that most children with ASD will benefit from therapies designed to improve their ability to communicate and engage in social interactions. For young and lower-functioning children, therapy may include highly structured, behaviorist approaches designed to teach a sequence of discrete skills such as vocal imitation, responses to specific words, and single word productions. Whereas many speakers with ASD develop more or less developmentally appropriate forms and meanings for words and sentences, deficits in the use of language for social purposes are universally seen in this population. These deficits can serve as major impediments to successful social adaptation and acceptance. Explicit training in social uses of language can be helpful to reduce these handicaps. Research has shown that intervention makes a difference, and that early intervention focused on communication and social skills can significantly improve the outlook for individuals on the spectrum. Children with autism have deficits in speech and language, as well as social communication. Therapists with experience working with children on the spectrum, handling the myriad of communication challenges that face these children, are most appropriate. In addition, research supports the utility of teaching social skills to children on the spectrum, with the expectation that skills learned in therapy can be generalized to different settings and people. According to experts, social skills deficits are a pervasive and enduring feature of ASD. Deficits in communication are integral to the diagnosis of autism and are the foundation for many of the clinical findings. The sooner and more aggressively these deficits are targeted, the better chance the patient has for developing adequate skills to function in the community. Speech and language therapy is therefore medically necessary and appropriate for this patient. In addition children on the autistic spectrum typically have complex deficits in the processing of extrinsic and intrinsic sensory information. Children with ASD have a range of occupational and performance problems that interfere with their full participation in school, home, and community activities. Predominant characteristics of autism that are often the focus of intervention include limited social interaction, delayed or deficit language, behavioral problems, and sensory-processing difficulties. With its focus on developing motor planning skills and self-help skills, developing age-appropriate communication skills (written and functional), processing information, and regulating the response to incoming information, occupational therapy (OT) is well suited to affect positive change in children with ASD. OT is therefore medically necessary and appropriate for this patient.