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

Nature of Statutory Criteria/Case Summary: An female enrollee has requested reimbursement for digital breast tomosynthesis performed. Findings:  The physician reviewer found that breast tomosynthesis is a technique that was developed several years ago as a problem solving adjunct to routine mammography.  Applying the same basic concept as computed tomography (CT) scanning, the logic is that by separating the various layers of breast tissue, one can better detect abnormalities.  This has been shown to be most useful in the evaluation of dense breasts.  In this patients case, the records noted heterogeneously dense breast tissue.  It is specifically those patients who have dense breasts that can benefit most from tomosynthesis.  The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor.  Thus, digital breast tomosynthesis performed on the date of dispute was likely to have been more effective than other methods of evaluating this patient. Final Result: The reviewers determined that the service at issue was 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 reviewers 1, 2 & 3 are board certified in diagnostic radiology 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

A forty-one year-old female with fibroids, ovarian cyst, menorrhagia, dysmenorrheal and dyspareunia is requesting a total abdominal hysterectomy.  Reviewers Response:The reviewing physician found that the submitted documentation reveals little objective evidence to support immediate surgical treatment. At this time, the patients symptoms are not so definitive as to preclude a trial of medical therapy to ensure that conservative treatment has been exhausted.  Therefore the reviewer found that the Health Plan denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Overturned

A female enrollee requested allogeneic stem cell/bone marrow transplant for medical treatment of her multiple myeloma and history of chronic lymphocytic lymphoma.  Findings:  Three physician reviewers found that her disease appears to be a highly aggressive variant that is refractory to two modern regimens, both of which have typically resulted in very high response rates. Thus, available standard therapies, such as high-dose chemotherapy followed by autologous stem cell rescue, are unlikely to be of benefit. Consistent with these findings, the requested allogeneic stem cell/bone marrow transplant is likely to be more beneficial for treatment of this patients medical condition than any available standard therapy.
Appeal type: Experimental/Investigational
Decision: Upheld

A 50-year-old female enrollee has requested carotid intima-media thickness testing for heart disease risk screening for evaluation of her history of hypercholesterolemia.  Findings:  Two physician reviewers found that in this clinical situation, the testing at issue was not likely to have been superior over other available tools for evaluating this patient. Guidelines for assessing the likelihood of obstructive coronary disease and managing cardiac risk are published, periodically updated by expert national committees, and endorsed by several national organizations.  These guidelines currently do not recommend the routine use of measuring carotid intima-media thickness to help assess the prevalence of coronary disease or to assess the risk for developing coronary disease.   There is a lack of data indicating that a change in treatment based on the testing at issue favorably effects cardiac outcome incremental to that achievable by treatment based on standard risk factor profiling alone.  Therefore, carotid intima-media thickness testing performed on the date in question was not likely to have been more efficacious than other methods of evaluating this patient.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested C2, C3 and C4 medial branch rhizotomy for treatment of the enrollees cervical facet arthropathy. Findings: The physician reviewer found that the review of the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested services. Manchikanti and colleagues reviewed the effectiveness of medial branch blocks in systematic reviews and randomized trials. Thoracic spine was noted to have evidence with controlled blocks Level II-1, moderate to strong evidence lasting from months to a year with level II-2 to II-3. Thoracic facet joint nerve blocks showed improvement in 71% of the patients at six months, 76% at 12 months, 71% at 24 months, and 69% at 36 months. In addition, Son and colleagues found that repeated radiofrequency ablation for lumbar facet syndrome provides successful pain relief for about 10 months in more than 85% of carefully selected patients. In this case, the patient states he received up to 10 months of relief with a prior rhizotomy. However, the medical records do not adequately document the nature of the patients neck pain or document that the patient has been treated with a prior rhizotomy 10 months prior. Given the lack of documentation demonstrating that previous rhizotomy has been performed, the request for C2, C3 and C4 medial branch rhizotomy has not been established as 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.Credentials/Qualifications: The reviewer is board certified in anesthesiology with sub-specialty certification in pain 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for radiofrequency ablation of the tongue (CPT 41530). Patients with mild to moderate obstructive sleep apnea (OSA) are candidates for submucosal radiofrequency tongue base ablation. Radiofrequency ablation of the tongue base and/or palate has been evaluated and reported to be safe and effective in the management of well-selected patients with OSA. Baba and colleagues evaluated temperature controlled radiofrequency tissue ablation for the management of patients with symptomatic OSA. The authors found that temperature controlled radiofrequency tissue ablation was clinically effective in reducing RDI [respiratory disturbance levels] and symptoms of sleepiness in patients with OSA syndrome when directed at the base of tongue or as a multilevel procedure. This patient presents with OSA associated with poor sleep quality with associated daytime sleepiness, fatigue, and decrease in sleep-related quality of life. The patient was reportedly intolerant to treatment with positive airway pressure (PAP) and his symptoms have persisted. Therefore, the requested radiofrequency ablation of the tongue (CPT 41530) is 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 requested radiofrequency ablation of the tongue (CPT 41530) is 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 services are 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 reviewer 1 is board certified in otolaryngology and is actively practicing. Physician reviewer 2 is board certified in otolaryngology and is actively practicing. Physician reviewer 3 is board certified in internal medicine with subspecialty certification in sleep medicine and is 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

The parent of a five-year-old female enrollee has requested for the Paradigm Real-Time continuous glucose monitoring system (CGMS) for treatment of the enrollees persistent hyperinsulinemic hypoglycemia of infancy (PHHI).  Findings:  Three physician reviewers found that the management of PHHI is difficult and these children are at risk for brain damage from repeated hypoglycemias. Persistently their high insulin levels may also inhibit alternative brain energy substrates such as ketones. Prevention of seizure requires numerous blood glucose measurements throughout the day and the night. The patient could be monitored more closely and be spared frequent finger-stick blood sampling through the use of a CGMS.
Appeal type: Experimental/Investigational
Decision: Overturned

A 53-year-old female enrollee has requested a computed tomography (CT) scan of the heart for evaluation of her chest discomfort. Findings:  Two physician reviewers found that the requested diagnostic procedure is likely to be more effective for this patient than other available options. Taylor and colleagues specify and rate criteria for the appropriate use of cardiac computed tomography. In symptomatic individuals with low or intermediate pretest probability and normal EKG, the test is considered appropriate with a score of 7 on a 1-9 scale. The authors also indicate that individuals with prior imaging stress tests like an MPI where the result is equivocal (negative chemical stress tests are equivocal compared with stress MPI) or normal the appropriateness score is 8 on a scale of 1-9.  Based on the documentation submitted for review, this patient is at an intermediate risk for coronary disease and it is likely to be more beneficial for treatment of the patients medical condition than other standard therapies.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for tonsillectomy and adenoidectomy for treatment of enlarged tonsils. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services. Per the records, this patients history of tonsil problems is not related to infection, but rather is related to tonsil enlargement resulting in airway compromise with snoring, nocturnal awakening and choking. Although the patient has a history of tonsil hypertrophy, there is no report submitted of evidence of sleep apnea documented on a sleep study. Given the absence of objective data showing sleep disorder, the medical necessity of the requested services has not been established. All told, the requested tonsillectomy and adenoidectomy are not medically necessary for the treatment of this patient. 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 otolaryngology 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 41-year-old female enrollee requested authorization and coverage of the medication Iressa. The Health Plan denied the request indicating that the requested medication is considered investigational for treatment of the enrollees pancreatic cancer. Three physician reviewers performed an experimental/investigational Independent Medical Review. All three physician reviewers concluded that the requested medication 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 medication 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

A forty-four year-old male with a history of cervical spondylosis, headaches and low back pain is requesting reimbursement for epidural injections.Reviewers Findings:  The reviewing physician found that the submitted medical records do not establish that the epidural steroid injection the patient received were medically necessary for treatment of the patients chronic pain.  The reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Urgent Care
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested surgical services and hospital stay on an emergent basis. The physician reviewer found that submitted documentation demonstrates that a prudent layperson would not have sought immediate medical attention on the dates in question. Upon review of the submitted medical records, the patient presented with a several year history of chronic regional pain. The patient does not have demonstration of instability in flexion extension films. There is no documentation of fractures or scoliosis. Moreover, the demonstrated spinal stenotic changes, central and neural foraminal are referenced in the anatomical studies but they can be dealt with in a patient without instability through a more limited posterior approach without fusion. In sum, the patient was not experiencing a serious medical condition that was likely to place the patients health in serious jeopardy, cause serious impairment to body functions or cause serious dysfunction to a body organ or part. Thus, the services did not meet prudent layperson criteria for emergency care. Final Result: The reviewer determined that the patients symptoms did not meet prudent layperson criteria for emergency care. Therefore, the Health Plans denial should be upheld.  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 parent of a 12-year-old female enrollee has requested skilled nursing facility (SNF) services for treatment of the enrollees grand mal seizures (poorly controlled) and developmental delays. Findings:  The physician reviewer found that in treating patients with epilepsy, the delivery of high-quality care is complicated by the complexity and diversity of symptoms. Overall, epilepsy has a pervasive impact on the lives of patients with intellectual disabilities and occurs more frequently in this patient population. Children and adolescents offer unique challenges as they are more likely to suffer lifelong intractable epilepsy with multiple seizure types. In addition, the younger patients often cannot clearly express their complaints about antiepileptic drug (AED) side effects, and the caregivers role becomes crucial as the patients advocate. Patients who have both epilepsy and intellectual disability have significant problems requiring skilled health care management. Clinical nurse specialists have the unique opportunity to work with these patients and their families to help them develop self-management and family management skills. Given this patients specialized needs, the requested skilled nursing care should be provided to better to provide her an optimal quality of life. Further, this skilled nursing care will prevent complications from the patients intractable epilepsy during this vulnerable time in the patients current situation. Moreover, the Health Plans criteria defining medical necessity for skilled nursing services provides care for an acute exacerbation of a chronic medical condition. Thus, it is therefore reasonable to extend these benefits to a minor patient who requires the care of a caregiver who is unable to provide such services due to an acute condition affecting the abilities of the caregiver to administer such care. Accordingly, the requested skilled nursing care should be provided this patient until such time that the primary care giver is capable of providing her care.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested Harvoni for treatment of his hepatitis C infection.  Findings: The physician reviewer found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. This applies regardless of fibrosis stage or viral load. Per the guidelines, treatment-naive genotype 1 patients should be treated with Harvoni. Patients with viral load can be treated. These guideline recommendations are based on multiple randomized clinical trials. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, the requested Harvoni is supported as medically necessary for the treatment of this patients hepatitis C infection.  Final Result: The reviewer determined that the requested medication is necessary for treatment of the patients medical condition.  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: Medical Necessity
Decision: Overturned

The parent of a four-year-old male has requested speech therapy for treatment of his speech delay.  Findings:  The physician reviewer found that in this patients case, the requested speech therapy is medically necessary to address moderate delays in speech and articulation skills and mild delays in expressive language skills.  As noted by Nelson and colleagues, speech and language development is considered by experts to be a useful indicator of a childs overall development and cognitive ability and is related to school success.  The authors noted that identification of children at risk for developmental delay or related problems may lead to intervention services and family assistance at a young age when chances for improvement are best.  Speech and language delay must be taken seriously in young children, because the long-term consequences may be substantial. According to Law and colleagues, approximately 6% of children have speech and language difficulties.  The authors noted that children whose difficulties persist into primary school may have long-term problems concerning literacy, socialization, behavior, and school attainment.  These reviewers concluded that there is a positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulties.  This patient demonstrates speech and language deficits, most prominent in his articulation skills, impacting his ability to communicate in a functional and age-appropriate manner.  Studies have shown that speech and language therapy can result in significant improvement in this clinical setting.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested vein surgery for treatment of his symptomatic varicosities. Findings:  The physician reviewer found that overall, the documentation does not support the medical necessity of the requested procedures for treatment of this patients bilateral leg pain. There is no venous duplex provided that demonstrates absence of deep venous obstruction or significant reflux in the veins selected for treatment. The records also do not adequately document that the patient was provided with a prescription for medical grade compression stockings and instructed in their use in a concerted effort to treat conservatively. Thus, the requested vein surgery is not medically necessary for treatment of this 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.  Credentials/Qualifications: The reviewer is board certified in vascular 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: Upheld

A 41-year-old female enrollee requested laboratory testing (immune cell function assay) for medical evaluation of her medical condition.  Findings:  Three physician reviewers found that in this case, the services at issue were not likely to have been more effective than other modalities for evaluating this patient.  The use of immune cell function assay for assessing the immunosuppressive status of patients who have received solid organ transplants has not been accepted as standard of care.  The existing studies do not support a sufficient diagnostic accuracy to identify patients at risk of rejection.  The International Society of Heart and Lung Transplantation guidelines have not recommended this test for routine clinical use until larger, randomized trials are available.  Therefore, the superior efficacy of immune cell function assay has not been established.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested Copaxone for treatment of her medical condition.  Findings:  The physician reviewer found that this patient has been diagnosed with relapsing-remitting multiple sclerosis.  She has had difficulty with injection site pain, and it is known that patient adherence can be impacted by side effects such as pain and injection site reactions.  Thus, three times weekly injections are likely to be less irritating and foster adherence.  Per the medical evidence, Copaxone, three times weekly has been shown to be safe and well-tolerated.  All told, Copaxone is medically indicated for the treatment of this patient.  Final Result: The reviewer determined that the requested medication 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.