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

The patient is a 60-year-old female with pulmonary hypertension. Her physician has stated her pulmonary pressures are elevated. She is taking multiple medications for management of her medical condition. In addition, her physician has recommended the addition of Viagra to the patients medication regimen for treatment of her pulmonary hypertension.The patient is a 60-year-old female with pulmonary hypertension. According to a hospital summary dated 7/15/04, the patient has multiple medical problems including pulmonary hypertension, systemic lupus erythematosus (SLE), congestive heart failure, hyperlipidemia, diabetes mellitus, and status post DVT/PE. Current medications include prednisone, Lasix, Aldactone, KC1, metformin, Pravachol, Lexapro, Coumadin, Toprol XL, lisinopril and supplemental oxygen.According to an office visit note dated 7/7/04 with her rheumatologist, the patient was found to have connective tissue disease with anticardiolipin antibody, pulmonary embolism, and pulmonary hypertension. The rheumatologist was unsure if the pulmonary hypertension was due to the patients pulmonary embolism or was primary pulmonary hypertension. The notes state the patient has not yet been assessed by a pulmonologist. Thereafter, Viagra was prescribed for treatment of pulmonary hypertension. There is indication in the file that the patients provider had consulted with several experts and they elected to use Viagra as a vasodilator for the treatment of pulmonary hypertension.The records do not indicate if the patient underwent acute vasodilator challenge with right heart catheterization. Studies show the patients who show more than 20% drop in vascular resistance may benefit from calcium channel blockers. In general, use of vasodilators in primary pulmonary hypertension may benefit such patients.Other medications have shown promise in the treatment of primary pulmonary hypertension such as bosentan and epoprostenol. Both medications have been approved by the Food and Drug Administration for use in pulmonary artery hypertension. Viagra has been utilized in the treatment of pulmonary hypertension, but studies are preliminary and there have been no controlled clinical trials.This patients pulmonary hypertension is most likely resulting from an underlying medical condition such as her SLE, CAD or previous pulmonary emboli. Secondary pulmonary hypertension is treated by treating the underlying cause. The overwhelming majority of pulmonary hypertension cases are secondary in nature and diagnosis of primary pulmonary hypertension is rare, especially in a 60-year-old female. Based upon this information, the patients pulmonary hypertension requires further evaluation.As set forth above, evidence regarding the use of Viagra (especially in a patient whose diagnosis requires further evaluation) in the treatment of pulmonary hypertension is preliminary and there are other proven medications available for this patient. Therefore, 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: Experimental/Investigational
Decision: Upheld

A 47-year-old male enrollee has requested Mepron for treatment of his Babesiosis. Findings:  Two physician reviewers found that the evidence indicating that this patient has Babesiosis is very limited. The disease is usually diagnosed by examination of blood smears and by a polymerase chain reaction (PCR) test. In this case, the patient did not present with the usual symptoms of this disease and he had an IgM antibody titer at a level of unclear significance as an antibody titer of less than 1:20 is reported as normal. Even if the test was repeated to confirm this level, alone it is not adequate evidence to make a diagnosis of Babesiosis. The treatment for this disease is usually Atovaquone and azithromycin, which is the regimen that the provider had planned to use. However, the Centers for Disease Control (CDC) recommendations suggest therapy for at least 7-10 days and do not recommend extending treatment beyond this period. All told, there is inadequate evidence in the peer reviewed medical literature showing that extending this period of treatment is necessary or appropriate in this clinical setting.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Caris Molecular Intelligence Profile test. Desmoid tumors are perceived as a malignant condition due to the aggressive growth pattern of the fibromatosis. Patients with desmoid tumors require a multidisciplinary approach for treatment (Penel, et al.; Schmitz, et al.). The invasive pattern and the presence of mutations make the desmoid tumors most akin to soft tissue sarcomas (Trautmann, et al.). Patients with refractory or relapsed cancer that have exhausted standard treatments are generally considered for clinical trials. Recently, it has become important to identify mutations that may be amenable to targeted therapy. Von Hoff and colleagues reported on 86 patients where the progression-free survival (PFS) on regimen selected by molecular profiling was compared to PFS on the last chemotherapy regimen. The authors found that the regimen selected by molecular profiling offered a 27% survival advantage. There are also reports of mutations identified by next generation sequencing that are responsive to imatinib (Trautmann, et al.). This patient has exhausted the current standard of care therapies for desmoid tumors. A clinical trial is reasonable as a targeted therapeutic approach based on molecular profiling. To help direct treatment, the Caris Molecular Intelligence Profile test was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Findings:  Two of the three physician reviewers found the Caris Molecular Intelligence Profile test was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewer  is board certified in internal medicine with subspecialty certifications in medical oncology and hematology and is actively practicing. Physician reviewer  is board certified in internal medicine with subspecialty certifications in medical oncology and hematology and is actively practicing. Physician reviewer  is board certified in internal medicine with subspecialty certification in medical oncology 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: Upheld

A 55-year-old female enrollee has requested trigger point injections for treatment of her vertebral disc pain. Findings:  Two physician reviewers found that at present, there is a paucity of medical literature providing support for the effectiveness for trigger point injections in patients with fibromyalgia or in the spinal region. Further, Staal and colleagues concluded of their systematic review that trigger point injections failed to show any significant benefits in managing patients with chronic pain. Thus, the requested therapy is not likely to be superior to standard, proven, accepted treatment modalities in this patients care.
Appeal type: Medical Necessity
Decision: Upheld

A forty-one year-old female with metastatic Stage IV endometrial stromal sarcoma is requesting authorization and coverage for an out-on-network CT scan.Reviewers Findings:  The reviewing physician found that there is no objective evidence that CT scanning performed by the in-network radiology center is inadequate or not within the standard of care.  The Health Plan denial was upheld.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 43-year-old female who has had a several year history of shooting right-sided pain in the neck, arm and body and headaches. She complains as well of swelling in the right axilla and other soft tissue areas of her right side extremities. Recent neck pain and headache has been associated with feelings of sweating and tachycardia. She has been seen by a neurologist. The submitted records include a negative plain spine x-ray and a normal EMG of pertinent peripheral nerve areas. On physical exam no discrete swelling or lumps have been noted. A Bruce exercise test performed because of substernal discomfort was normal and the patient exercised to Stage 4. Neurology exams are within normal limits. There has been some physical therapy without significant relief. A skin biopsy showed a non-specific resolving dermatitis. MRI of the cervical spine has been requested but denied by the Health Plan on the basis that it is not medically necessary.The patients records provide no basis for the necessity of an MRI of the cervical spine. No history, signs or symptoms are documented indicating that a structural abnormality of the cervical spine may be the cause of the patients pain. Furthermore, x-rays of the cervical spine were normal. The Health Plan is correct; there is insufficient evidence to demonstrate the requested MRI is medically necessary. Therefore, the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 14-year-old female enrollee requested residential treatment center (RTC) services for medical treatment of the enrollees behavioral health condition.  Findings:  The physician reviewer found that the patient has a concerning depressive illness and OCD disorder with contemporaneous treatment refusal, parental pathology and a home environment, which in its current state, is not conducive to meaningful treatment gains. The patient has a formidable symptom complex that is impairing multiple domains of functionality and jeopardizing her developmental task of identity formation. Additionally, the patients impulsivity and dysphoria have resulted in several potentially harmful situations. Her parental relations are disharmonious and disarrayed. She does not have a nurturing and reliable relationship with an adult figure or a supportive peer group. Finally, the patient has failed less restrictive interventions. Therefore, treatment at the residential level of care in this case is reasonably expected to improve her condition and prevent a more serious episode of illness.
Appeal type: Medical Necessity
Decision: Overturned

A 21-year-old female enrollee requested authorization and coverage of continued participation in an intensive outpatient program. The Health Plan denied the request indicating that the requested services are not medically necessary for the treatment of the enrollees eating disorder.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plans denial on the basis that the requested services are medically necessary.
Appeal type: Experimental/Investigational
Decision: Overturned

A 61-year-old female enrollee  requested a breast magnetic resonance imaging (MRI) with contrast for medical evaluation of her medial right breast asymmetry.   Findings:  Two physician reviewers found that this patient has a persistent abnormality on mammography seen on only one view and the finding has increased in size over the past few exams. There is no correlate on alternate views and ultrasound has been negative. The exclusion of a deep mass within the breast as well as the chest wall remains the primary concern. Due to limitations with mammography and ultrasound, the requested MRI remains the best tool for evaluation. Due to the highly sensitive nature of MRI in the detection of breast masses, the requested exam would be of more benefit to this patient than any other technique.
Appeal type: Medical Necessity
Decision: Overturned

A 60-year-old female enrollee requested authorization and coverage of physical therapy. The Health Plan denied the request indicating that the requested therapy is not medically necessary for treatment of the enrollees lymphedema.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plans denial on the basis that the requested therapy is medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting authorization and coverage for neck surgery. The enrollee has neck pain. At an office visit, the orthopedic surgeon reported the enrollee had radiation of his neck pain to his arms and numbness of his right hand. The enrollee walks with his head thrust forward and can bring his head to neutral, but with significant pain. The surgeon reports an x-ray of the cervical spine showed significant degeneration. Magnetic resonance imaging of the neck revealed stenosis and marked kyphosis, with pressure on the anterior cord causing displacement. The outcomes of anterior cervical discectomy and fusion are generally positive.  A systematic review of studies found good outcomes. Evidence in the literature suggests superior surgical outcomes in anterior cervical discectomy and fusion procedures with anterior plate fixation.  A literature review also found that anterior cervical discectomy and fusion was the dominant strategy for individuals with radiculopathy; compared to non-operative options, such as epidural injections.Final Result: The reviewer determined that the requested service is medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician 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 similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has reimbursement for leukocyte histamine release test (CPT 86343) for evaluation of the enrollee who has a history of asthma and eosinophilic esophagitis. Findings:  The physician reviewers found that there is a lack of support for the superior efficacy of the services at issue in this clinical setting. This patient has a history of asthma, allergic rhinitis, dermatographism and EoE.  In this patients case, there is no diagnosis of chronic uncontrolled urticaria, only dermatographism which is a physical urticaria. Laboratory evaluation has failed to confirm an autoimmune process.  The services at issue is a leukocyte histamine release assay.  At this time, the clinical utility of this test is not well established and there are currently no national allergy and  immunology or dermatology guidelines recommending routine use of this test. At this time, this test is not needed to make a diagnosis of chronic urticaria, guide therapy or follow for clinical disease course. The current guidelines recommend against screening. The records do not show that this patient has tried and failed standard therapy. For these reasons noted above, leukocyte histamine release test (CPT 86343) was not likely to have been of greater benefit than other standard treatment methods for the evaluation of this patients medical condition. Final Result: All three reviewers determined that 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: Physician reviewers number one, two, and three are board certified in allergy and immunology and 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: Upheld

A 55-year-old male enrollee has requested a LifeVest wearable cardioverter defibrillator for treatment of his myocardial infarction.  Findings:  Two physician reviewers found that based on the records provided, the patient presented with an acute myocardial infarction associated with severely reduced LVEF of less than 35%. In this circumstance of newly diagnosed severe left ventricular (LV) dysfunction in the setting of an acute myocardial infarction, there is potential for recovery of LV function after revascularization, time and medical therapy. There is no indication for immediate placement of a defibrillator such as sustained or inducible ventricular tachycardia, syncope or aborted sudden cardiac arrest. Placement of a prophylactic defibrillator is not recommended until 40 days after myocardial infarction where continued severe LV dysfunction is documented to persist in spite of appropriate treatment (Epstein, et al). Studies assessing the efficacy of prophylactic defibrillators early after diagnosis of myocardial infarction and reduced LVEF of 35% or less before ventricular function has had a chance to recover have not demonstrated improved outcome (Hohnloser, et al; Steinbeck, et al). Consistent with these findings, the LifeVest device provided to this patient from the time frame specified was not likely to have been more beneficial than standard available therapies.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for magnetic resonance imaging of the spine for evaluation of the enrollees low back pain. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity for the requested service. The medical literature supports an imaging study if it will change the course of therapy. In this patient, who has a relatively new onset of low back pain and who has an absence of preexisting conditions, such as a tumor or indications of an acute infection, the general practice is to proceed conservatively. The American College of Radiology (ACR) has established appropriateness criteria to evaluate various clinical presentations, including low back pain.  The guidelines indicate that imaging patients with acute low back pain, of less than six weeks duration and no red-flag symptoms provides no clinical benefit (ACR Appropriateness Criteria).  The ACR criteria also recommends that in patients with chronic low back pain, who do not present with red flags, first-line treatment remains conservative therapy with both pharmacologic and nonpharmacologic (eg, exercise, remaining active) therapy without imaging. In this patients case, there is no indication that she has specific neurological signs or radiculopathy. There is no information submitted that she has undergone a course of conservative anti-inflammatory medications or physical therapy.  There is also no information submitted that the patient has had any prior imaging studies including plain x-rays. The medical literature and the guidelines recommend conservative therapy, both pharmacologic and nonpharmacologic, prior to initiating further diagnostic therapies. In this case, the documentation does not show that she has exhausted conservative management. All told, conservative management is warranted, prior to undergoing MRI of the spine.  For these reasons, MRI of the spine is not medically necessary for the evaluation of this patients medical condition. 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: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Lyrica for treatment of her fibromyalgia.  The physician reviewer found that the submitted documentation supports the medical necessity of the requested medication.  This patient has contraindications to multiple preferred agents for fibromyalgia.  Lyrica is approved by the U.S. Food and Drug Administration and is indicated for the management of fibromyalgia.  This patients comorbid condition of end-stage liver disease limits her medication options.  There is sufficient support for the requested medication in this clinical setting.  All told, the requested medication Lyrica 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 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: Medical Necessity
Decision: Overturned

The parent of a 12-year-old male enrollee has requested occupational therapy for the treatment of the enrollees autism. Findings:  The physician reviewer found that the American Occupational Therapy Association (AOTA) clearly supports the use of OT services for the purposes of treating functional deficits in patients with autism as outlined in their guidelines. This patient has both fine and motor delays that are affecting his ability to attend to self-care and independence in the community. The provider references specific treatment goals and the patients progress toward achieving those goals in the progress reports. It is clinically appropriate for this patient to receive OT services from a skilled therapist as he continues to make gains but has not yet achieved the realistic milestones for a young person his age.
Appeal type: Medical Necessity
Decision: Overturned

The parent of an 8-year-old female enrollee has requested speech therapy once per week for 30 minutes for treatment of the enrollees Aspergers syndrome. Findings: The physician reviewer found that Aspergers syndrome includes significant social skills deficits with fair communication skills and marked circumscribed interests. Children with Aspergers syndrome are typically severely socially impaired especially when exposed to peers. Language deficits are often one of the core aspects of Aspergers syndrome and speech therapy provides professional help and guidance in appropriate communication development. Goldstein reviewed communication interventions in peer-reviewed research articles published over the past 20 years and found that the evidence supported the claim that effective interventions exist to teach communication skills to children with autism spectrum disorder. Language skills can make a significant difference in the ability of autistic children to control their environment and has a profound impact on their functional abilities function on a daily basis. The guidelines established by the National Research Council (2001) include building spontaneous functional communication skills as a core aspect of effective treatment for children with autism at all ages and levels of disability. Given this patients level of disability within pragmatics and socialization, the requested speech therapy is medically necessary.