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

Nature of Statutory Criteria/Case Summary:   An enrollee has requested genetic testing Decision Dx melanoma assay for evaluation of his medical condition.  Findings:  The physician reviewer found that review of the submitted documentation and relevant literature demonstrates the medical necessity of the services at issue. Decision Dx melanoma assay is utilized to help predict future metastatic risk of his invasive melanoma. In this case, the patient was diagnosed with an invasive melanoma, which requires excision for definitive treatment. Subsequent follow-up is aimed at identifying recurrences or the development of distant metastases. Once metastatic, treatment of melanoma is very challenging and not very successful. The Decision Dx melanoma assay identifies the molecular fingerprint of the melanoma and tests for the expression of genes which have a higher or lower risk of future metastasis.  The patients Decision Dx result showed a pattern of gene expression which is associated with an increased risk of the development of metastatic disease. This information, in conjunction with the diagnosis of invasive melanoma changes the patients treatment course. For instance, with this information, the patient may pursue a more aggressive treatment course with therapy that may otherwise be considered controversial, such as interferon injections or shorten the interval between imaging studies to identify metastatic lesions at an earlier time. All told, the Decision Dx melanoma testing was clinically indicated for treatment of this patients invasive melanoma. Final Result: The reviewer determined that the services at issue were medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications:   The reviewer is board certified in dermatology 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

This patient is a 16-year-old female with a history of bronchiectasis and recurrent pneumonias; however, she apparently does not have cystic fibrosis. Her provider has recommended an IPV device to help prevent widespread bronchiectasis. The information provided does not demonstrate why manual percussion and postural drainage or a flutter valve and acapella have not been effective.Although there is literature documenting the effectiveness of an IPV device in the treatment of cystic fibrosis, because this patient does not have cystic fibrosis, such evidence is not necessarily applicable to this patients condition. Furthermore, the patient should attempt manual percussion and postural drainage or a flutter valve and acapella prior to consideration of an IPV device. If the patient attempts and fails the alternative treatments listed then an IPV device should be considered. However, based upon the information provided and no evidence that the patient has attempted and failed the available alternative treatments, I have determined an IPV device is not medically necessary at this time. Therefore, the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for residential treatment center services forward. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of a portion of the services at issue. On the date of dispute the patient had mild post-acute withdrawal symptoms with a low CIWA of 5, and he was medically and psychiatrically stable. Regarding emotional, behavioral, and cognitive factors, he remained highly anxious and required medications as needed. He was behaviorally appropriate and cognitively intact. However, he was described as having no coping skills and requiring education. He had never been to meetings or had contact with any type of treatment at any level of care. His drinking had escalated since high school, essentially for the past seven years since age 18, to the point of drinking a fifth a day. He drives while intoxicated and blacks out, creating hazardous situations for himself and others. He had no sober support. These factors made for a very high risk for relapse. Residential treatment afforded medically appropriate services so that he could develop a modicum of coping skills and identify relapse triggers. Residential services also provided him with exposure to a 12-step program and with contacts to take with him into the community. Therefore, residential treatment center services from date of dispute for  three days were medically necessary but not thereafter.Final Result: The reviewer determined that the services at issue was medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned. 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: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for risedronate for treatment of the enrollees osteoporosis. Findings:  The physician reviewer found that the request for risedronate is not medically necessary for treatment of the patients medical condition. The Health Plans recommendation of failure of the preferred drugs that include Fosamax and Boniva is medically reasonable and appropriate. The medical records provided for review fails to demonstrate that the patient has tried and failed treatment with Boniva. All told, the request for risedronate is not medically necessary for treatment of the patients medical condition. 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 rheumatology 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 50-year-old female enrollee has requested radiofrequency neurolysis for treatment of her pain.  Findings:  Three physician reviewers found that the current peer-reviewed literature supports the efficacy of radiofrequency neurolysis in the treatment of chronic back pain due to lumbar facet and sacral joint arthropathy. Gofeld and colleagues performed a 10-year prospective clinical audit of lumbar radiofrequency denervation. They concluded in the study that proper patient selection and anatomically correct radiofrequency denervation of the lumbar zygapophyseal joints provide long-term pain relief in a routine clinical setting. This patient is a good candidate for this procedure. She reported reduction in her pain for four to five months following lumbar medial branch blocks.  Geurts and colleagues concluded that there is moderate evidence that radiofrequency lumbar facet denervation is more effective for chronic low back pain than placebo. Van Kleef and colleagues performed a randomized trial of radiofrequency lumbar facet denervation for chronic low back pain. The study concluded that radiofrequency zygapophyseal joint denervation results in a significant alleviation of pain and functional disability in a select group of patients with chronic back pain. This patient has failed to receive any pain relief with anti-inflammatories and opiates. In addition, the patient reported a decrease in pain following the lumbar facet diagnostic blocks.  In this patients case, the requested radiofrequency neurolysis is likely to be superior over other treatment alternatives.
Appeal type: Medical Necessity
Decision: Upheld

A 60-year-old female enrollee has requested Omnaris 50mg spray for the treatment of her chronic sinusitis. Findings:  The physician reviewer found that Omnaris is a newer drug used in the treatment of allergic rhinitis and asthma.  Because it is administered as a pro-drug, it has been seen to have an improved therapeutic margin with no measurable effect on the hypothalamo-pituitary-adrenal (HPA) axis. On occasion, it has been prescribed at higher doses in patients with severe asthma. However, the use of this drug at the proposed dosage is not supported by the current literature. Given that the requested dosage is twice the dosage recommended by FDA guidelines and the effects of such dosage have not been studied, the Health Plans denial is medically appropriate in this case.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a six-year-old male has requested speech therapy for treatment of his autistic disorder and childhood apraxia of speech. Findings:  The physician reviewer found that children on the autistic spectrum 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. While school services are essential, they are not sufficient for children with the severity of deficits as seen in this patient. The more aggressively these deficits are targeted, the better chance the patient has for developing adequate skills to function in the community. The speech therapy at issue therefore was and is medically necessary and appropriate for this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: A female enrollee has requested authorization and coverage for the placement of a LINX augmentation device esophagus. The Health Plan has denied this request indicating that the requested procedure is considered investigational for treatment of the enrollees gastroesophageal reflux disease (GERD).The LINX System has not been studied in patients with Barretts esophagus. Although this patient has a confirmed diagnosis of GERD, Bravo pH testing revealed poor symptom correlation with acid reflux. In addition, implantation of LINX in this clinical setting must be approached with caution given her underlying Barretts esophagus. As such, the placement of a LINX augmentation device esophagus is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested procedure is 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: Physician reviewers 1, 2 and 3 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: Experimental/Investigational
Decision: Overturned

A 51-year-old female enrollee has requested migraine surgery for treatment of her migraine headaches.  Findings:  Two physician reviewers found that based upon the submitted documentation, the surgery resulted in complete elimination of this patient's migraines. In this patients case, migraine surgery was likely to have been more efficacious than other available treatment modalities.  She had already tried multiple standard and nonstandard therapies for migraine headaches, and none provided lasting benefit. Surgery for intractable migraine headaches has been shown to be beneficial, especially for patients who have failed standard therapy.  The current medical evidence indicates that surgical deactivation of peripheral migraine trigger sites is an effective alternative treatment for patients with frequent moderate to severe migraine headaches that are difficult to manage with standard protocols.  Therefore, the superior efficacy of the procedure at issue has been established in this clinical scenario.
Appeal type: Medical Necessity
Decision: Upheld

Findings:  The physician reviewer found that The parents of an enrollee has requested authorization and coverage for dermatology services (including office visit and biopsies) at a clinic offering pediatric tertiary care.Removal of benign nevi for biopsy is a very common procedure that is performed by all dermatologists. Cohen states, Most dermatologists evaluate children and adolescents who have changing moles. Moreover, most of those patients are evaluated by general rather than pediatric dermatologists. Nevi or moles affect all ages and a board certified dermatologist is qualified to treat these conditions. A board certified dermatologist is qualified to treat children and adults and can adequately assess and biopsy or treat patients of all ages. As moles occur in adults and children, there is no medical reason, this patient needs to be seen by the tertiary care pediatric dermatologist. Therefore, dermatology services (including office visit and biopsies) at a clinic offering pediatric tertiary care are not medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Overturned

A 53-year-old female enrollee has requested approval  for past computer aided detection (CAD) with magnetic resonance imaging (MRI) of the breast for evaluation of her medical condition.   Findings:  Two physician reviewers found that the patient was diagnosed with a low grade breast cancer seven months ago. She had had a history of fibrocystic changes, but a mammogram demonstrated abnormal appearing calcifications and she ultimately underwent a stereotactic biopsy. Following the initial biopsy, she underwent a breast magnetic resonance imaging (MRI). The purpose of this MRI was to evaluate the extent of disease and to exclude additional lesions.  One of the recognized indications for a diagnostic MRI of the breasts is to evaluate the extent of disease and to determine whether there might be additional lesions that may eliminate the possibility for breast conserving surgery. One critical issue with breast MRI is the lack of specificity. MRI studies of the breast are highly sensitive, but are not at all specific. It is for this reason that MRI interpreters generally utilize CAD, in an effort to distinguish malignant changes. This is in contrast to the use of CAD in routine mammography where the goal is to increase sensitivity. With routine mammography, one generally only is concerned with two or three images of each breast. But with breast MRI, the provider generally has to evaluate hundreds of images, and CAD has become an integral tool in the general practice of radiology. However, there are conflicting results in the peer-reviewed medical literature. Arazi-Kleinman and colleagues state that, breast MRI CAD system used could not improve the radiologists accuracy for distinguishing all malignant from benign lesions, due to the poor sensitivity for DCIS detection. This patient had a lobular carcinoma in situ. Meeuwis and colleagues noted that, CAD-based analysis improved the specificity compared with manual analysis of enhancement. Automated analysis at 50% and 100% thresholds showed a high sensitivity and specificity for readers with varying levels of experience.In this patient with known malignancy, there was a need to exclude more widespread involvement and prepare for surgical planning. As such, CAD was reasonably expected to provide an added value to this patients evaluation and treatment and should therefore be approved.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested direct applied behavioral analysis (ABA) therapy for treatment of the enrollees autism spectrum disorder (ASD).  Findings: The physician reviewer found that the request for 19.5 hours per week of direct ABA therapy and 10 hours per month of supervision has not been established as medically necessary for treatment of the patients ASD. Remington and colleagues indicate that autistic children who are responsive to ABA therapy will do so within two years of the onset of therapy. The medical literature also shows that for older autistic children, the direction of therapy is to decrease ABA hours in favor of group and social activities to increase the patients social and community skills (Reichow, et al; Matson, et al). This patient has been receiving intensive ABA therapy from the same provider for more than three years with only modest improvements in most recorded parameters, but he is still having significant issues with health related matters and repetitive behaviors. In this clinical setting, a reduction of the ABA hours is medically reasonable. The Health Plans authorization of 60 hours per month of direct ABA therapy, six hours per month of supervision and two hours per month of parent training is medically appropriate for treatment of the patients ASD.  Final Result: The reviewer determined that the requested services 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 pediatrics with sub-specialty 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

Nature of Statutory Criteria/Case Summary: The patient was born at 38 weeks gestation via emergency cesarean section due to fetal distress. The patients birth weight was seven pounds one ounce. Her weight was seven pounds nine ounces, which placed her in the 53rd percentile. The patients weight was seven pounds 15 ounces. She was breastfeeding and taking supplemental formula. The records noted that the patient did poorly on Enfamil. Therefore, Similac was started, and the patient did well. Her weight was nine pounds five ounces, which placed her in the 56th percentile. The patients weight was 13 pounds four ounces, which placed her in the 48th percentile. The patients parent has requested authorization and coverage for Similac Pro-Advance, non-GMO powder 2.07 g-5.6 g, 4 oz given every 6 hours up to 32 oz per day. The Health Plan denied the request and reported the requested formula is not medically necessary for the treatment of this patient. At issue in this case is whether Similac Pro-Advance, non-GMO powder 2.07 g-5.6 g, 4 oz given every 6 hours up to 32 oz per day is medically necessary for the treatment of this patient. Martin and colleagues reported, Infant formula is intended as an effective substitute to breast milk and is formulated to mimic the nutritional composition of breast milk. Similac Pro-Advance non-GMO formula is a standard infant formula with added prebiotic. In this case, the patient has been maintaining adequate weight gain from birth. She regained her birth weight in less than one week and has consistently been around the 50th percentile for weight. There was only one reference in the medical records to the patients difficulty feeding. In the absence of specific details of feeding intolerance, such as vomiting, arching, fussing around feedings, weight loss, or diarrhea, there is no medical necessity for a specialty formula or one standard formula over another. The medical evidence does not support the requested formula in this clinical setting. Therefore, Similac Pro-Advance, non-GMO powder 2.07 g-5.6 g, 4 oz given every 6 hours up to 32 oz per day is not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested formula 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 pediatrics with sub-specialty 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: Overturned

Nature of Statutory Criteria/Case Summary: The patient has been diagnosed with chronic migraine. The records noted that the patient had four migraine headaches in the previous month, lasting approximately eight hours. The provider noted that prior to the patient beginning treatment with Botox, the patient had 26 migraines each month, lasting approximately 14 hours. The patients migraines have decreased by 22 migraines per month since beginning treatment with Botox. In an application for independent medical review, the patient reported that she has had Botox injections in the past, and by the 11th week after injection the medication had completely worn off, resulting in daily migraine headaches. The patient reported previously receiving Botox injections every 11 weeks, which resulted in an improved quality of life. The patient has requested authorization and coverage for Botox 200 unit (HCPCS J0585) injections at a frequency of every 11 weeks. The Health Plan denied the request and reported the requested medication regimen is not medically necessary for the treatment of this patient. The Health Plan has approved Botox (J0585) 200 unit injections, one treatment every 12 weeks, for a maximum of four treatments. At issue in this case is whether Botox 200 unit (HCPCS J0585) injections at a frequency of every 11 weeks are medically necessary for the treatment of the patients medical condition. The pharmacologic profile of OnabotulinumtoxinA makes it an appealing candidate for chronic migraine patients. Its good safety profile makes Botox the best option when other preventive medications are poorly tolerated or ineffective. Several studies have demonstrated that repeated injections over time are able to increase the benefit obtained after the first cycle of treatment, with a prophylactic cumulative effect. In this case, the patient had previously received Botox injections at an interval of every 11 weeks with benefit. The patient has reported that with Botox injections at an interval of every 12 weeks, she is experiencing two weeks of constant migraine headache four times per year. The medical evidence supports the requested medication regimen in this clinical setting. Therefore, Botox 200 unit (HCPCS J0585) injections at a frequency of every 11 weeks are 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 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.