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

Nature of Statutory Criteria/Case Summary:   An enrollee has requested bilateral breast tomosynthesis for evaluation of her medical condition. Findings:  Three physician reviewers found that there is sufficient support for the services at issue in this clinical setting. Breast tomosynthesis provides advantages to radiologists interpreting mammograms, especially in women with dense tissue.  This new method often allows the reader to separate dense glandular elements from underlying mass/architectural distortion, resulting in a decrease in biopsies, decrease in callbacks and increase in diagnostic accuracy and detection of small cancers.  Thus, the addition of tomosynthesis to the usual two-dimensional protocol was likely of greater benefit to the patient than had her examination been done with two-dimensional imaging alone.  Final Result: Three reviewers determined that the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: All three reviewers are board certified in diagnostic radiology 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

The patient has requested authorization and coverage for physical therapy and occupational therapy, five times a week. The records provided for review document that this patient does not require the specialized skill, knowledge and judgment of a qualified therapist to safely and effectively provide medically necessary and reasonable treatment five days per week. The documentation does not reveal that the patient can tolerate five days per week therapy, given his inguinal pain, which is causing mobility limitations. The patient remains non-ambulatory and his progress in physical and occupational therapy has been slow due to right groin hernia. All told, the requested physical therapy and occupational therapy five times per week is not medically necessary for 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 physical medicine and rehabilitation with subspecialty certification in neuromuscular 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: Upheld

A 53-year-old female enrollee has requested Ixempra in combination with Avastin for treatment of her metastatic breast cancer. Findings:  Three physician reviewers found that the use of this combination of Ixempra with Avastin has not been demonstrated to be beneficial or safe in patients with breast cancer in the peer reviewed published clinical literature. Further, this combination is not approved by the Food and Drug Administration (FDA), compendium listed or recommended by the consensus expert panel guidelines. Given the lack of evidence of the effectiveness of the proposed combination therapy, there is inadequate justification for the use of the requested Ixempra and Avastin therapies in these circumstances.
Appeal type: Medical Necessity
Decision: Overturned

A fifty-six year-old male with diabetes type II and cardiac and renal complications is requesting reimbursement, authorization, and coverage for continuation of treatment with Byetta.  The patient was not optimally controlled on three oral agents and a very small dose of bedtime NPH insulin.Reviewers Findings:The reviewing physician found that Byetta is presently indicated as adjunctive therapy to improve glycemic control in patients with diabetes mellitus type II who are taking other medications, alone or in combination, but have not achieved adequate control.  The reviewing physician found that the Health Plan denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

A 38-year-old female enrollee has requested a continuous passive motion (CPM) machine for the treatment of her right knee microfracture of the lateral femoral condyle. Findings:  The physician reviewer found that the continuous passive motion (CPM) device is appropriate, especially after complicated surgery as described by this patients treating physician. The equipment in this case was justified to help with healing and nourishment of the articular cartilage. The device was medically necessary for the patients post-operative recovery.  The article by ODriscoll and Giori outlines that stiffness following joint surgery progresses as a result of four stages (bleeding, edema, granulation tissue and fibrosis). CPM is effective when initiated early after the procedure and continued through the first two stages, until there is no further development of edema. This involves starting the procedure while the patient is hospitalized and continuing treatment after discharge. There is data from animal models that have shown CPM enhances healing of cartilage.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a one-year-old female enrollee has requested  for anakinra (Kineret) for treatment of the enrollees cryopyrin-associated periodic syndrome.  Findings:  The physician reviewer found that the scientific data indicates that CAPS is due to excessive IL1 beta release. The medication Kineret inhibits IL1 receptors, and moderates various types of inflammatory processes. While use of Kineret is currently not specifically approved by the Food and Drug Administration (FDA) for treatment of CAPS, this patient has not achieved control of her exacerbations until she was treated with Kineret. In addition, several studies provide support of the efficacy and safety of Kineret in young patients with CAPS, and described as providing a dramatic response by Shinkai and colleagues. Similarly, Lepore and colleagues concluded of their review that, Long-term IL-1 blockade produces a significant and persistent improvement in the clinical manifestations associated with the disease and on the overall quality of life. Consistent with these findings, the medical necessity of the requested Kineret medication has been adequately established in this case.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has been diagnosed with testicular hypofunction. Laboratory results dated 11/7/19 revealed a testosterone level of 251 ng/dL. The provider noted the patient has been treated with testosterone, and testosterone had helped his libido. In the Health Plan Prescription Drug Prior Authorization or Step Therapy Exception Request form, the provider noted that the patient has failed AndroGel and Androderm. The patient has requested authorization and coverage for testosterone cypionate 300 mg injected every two (2) weeks. The Health Plan denied the request and reported the requested medication is not medically necessary for the treatment of this patient. At issue in this case is whether testosterone cypionate 300 mg injected every two (2) weeks is medically necessary for the treatment of the patients medical condition. Researchers reported, We recommend testosterone (T) therapy for men with symptomatic T deficiency to induce and maintain secondary sex characteristics and correct symptoms of hypogonadism after discussing the potential benefits and risks of therapy and of monitoring therapy and involving the patient in decision making. Authors reported, Evidence shows that men with age-related low testosterone (testosterone threshold, less than or equal to 10.4 nmol/L [300 ng/dL]) may show small improvements in sexual functioning. In this case, the patient was diagnosed with testicular hypofunction and has been treated with testosterone for a low testosterone level of 251 ng/dL. The medical evidence supports the requested medication in this clinical setting. Therefore, testosterone cypionate 300 mg injected every two (2) weeks is medically necessary 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 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: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for left heart artery/ventricle angiography (CPT code 93458). Current guidelines for recommending invasive diagnostic testing with cardiac catheterization and coronary angiography for patients with known or suspected stable ischemic heart disease, such as this patient, include patients who have features on noninvasive diagnostic testing of potentially high risk coronary disease. This includes findings on myocardial perfusion imaging of large areas or multiple areas of reversible ischemia which would correspond to a summed difference score of greater than 8. The patient was found to have a small area of lateral wall ischemia with the summed difference score of 1. In an otherwise stable patient, this finding does not indicate high-risk anatomy that warrants an invasive procedure such as cardiac catheterization. No other findings on clinical examination or other noninvasive testing support cardiac catheterization in this patient. Given these findings, the requested left heart artery/ventricle angiography (CPT code 93458) is not medically necessary for evaluation of the patients medical condition.Final Result: The reviewer determined that the requested services are 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 internal medicine with sub-specialty certification in cardiovascular disease 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 reimbursement for residential detoxification services. The submitted documentation supports the medical necessity of the residential detoxification services. The American Psychiatric Association treatment guidelines for Substance Use Disorders recommends that residential treatment, or similar care higher than outpatient, is indicated for patients who do not meet the clinical criteria for hospitalization but whose lives and social interactions have come to focus predominantly on substance use, and who lack sufficient social and vocational skills and drug-free social supports to maintain abstinence in an outpatient setting. Such patients require safe and stable living environments in order to develop their recovery skills, thus qualifying for ASAM Level III treatment, which is at least residential or inpatient treatment similar to what the patient received at the facility. In this case, the patient had severe illness and continued his use of drugs despite the risks of DUI to self (including incarceration) and others. The patient also had a remitting relapsing illness despite many prior engagements in treatment. Under these circumstances, residential detoxification services were in accordance with generally accepted standards of medical practice and were clinically appropriate for the patient's illness. Accordingly, the residential detoxification services provided to the patient were medically necessary for treatment of the patients condition.Final Result: The reviewer determined that the services at issue were medically necessary for treatment of the patients condition. Therefore, the patient should be reimbursed for the services at issue, and the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 61-year-old female enrollee requested authorization and coverage of  sclerotherapy for the treatment of spider varicose veins. The Health Plan denied the enrollees request indicating that the requested treatment is not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer upheld the health plans denial on the basis that the requested services are not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 66-year-old male enrollee has requested authorization and coverage for a prescription of 30 or 60 Amerge per month and a prescription of 20 Imitrex per month. The Health Plan denied the request indicating that the requested prescriptions are not medically necessary for treatment of the enrollees headaches.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested prescriptions are not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 62-year-old male with a history of coronary artery disease, chronic obstructive pulmonary disease, cardiomyopathy, AICD, sleep apnea, diabetes mellitus, Raynaud's syndrome, elevated lipids, and osteoarthritis. The results of an in-home evaluation indicate the patient is independent in stand/pivot/slide transfers, independent in ambulating 150 feet in home and can stand/ambulate for 10 minutes. The primary care provider notes document multiple medical problems and also indicate that knee surgery is scheduled. Functional skills are not documented. A power-operated vehicle (POV) has been requested for community mobility. The Health Plan has denied the request on the basis the requested equipment is not medically necessary.The patient does not meet nationally accepted medical necessity criteria for authorization of a POV. Review of the submitted records indicates the patient is ambulatory in the home and the POV has been requested only for community mobility. Furthermore, there is no indication the patient cannot operate a manual wheelchair. As such, there is no evidence a POV is medically necessary for this patient. Therefore, I have determined the requested equipment is not medically necessary for the patients mobility. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

A 55-year-old female has requested eye movement desensitization and reprocessing (EMDR) for treatment of her stated condition of post-traumatic stress disorder.  Findings:  The physician reviewer found that based on review of the available records, the patient indicated that EMDR is preferable to the services offered to her including antidepressant medication, individual psychotherapy, and participation in a recovery group. However, given the details of the patients clinical history, there is inadequate documentation to support the medical necessity for the use of EMDR for this patient. As noted by the American Psychiatric Association (APA), the standard of care for this patients symptoms remains antidepressant medication, individual and group therapy as appropriate for her ongoing care. All told, the requested therapy is not supported as medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for platelet-rich plasma (PRP) injections. In patients with symptomatic osteoarthritis, PRP injections can result in significant clinical improvements up to 12 months post injection. Moreover, current data suggests that clinical outcomes are superior when compared to corticosteroids or viscosupplementation. This has been extensively studied in knees and also applies to hip osteoarthritis. In this case, the patient is unable to undergo total hip arthroplasty due to the severe muscle weakness and instability. Therefore, the goal of treatment is to achieve pain relief without surgical intervention. Among the options available, PRP has the highest probability of long-term pain relief without significant risk of complications. Moreover, this patients provider documented excellent results with prior PRP injections. As such, the requested PRP injections are medically necessary for management of the patients medical condition.Final Result: The reviewer determined that the services at issue are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The patient has requested authorization and coverage for MRI of the left foot. Latt and colleagues note that MRI may be used to confirm the presence of plantar fasciitis but is most useful in excluding the presence of other causes of heel pain such as calcaneus stress fracture, Baxter neuritis, tarsal tunnel syndrome, and insertional Achilles tendinopathy. In this case, the records document that the patient has reported ongoing pain in the left heel for several months despite conservative treatments, including activity modification, controlled ankle movement (CAM) boot immobilization, nonsteroid anti-inflammatory medications, icing, and stretching. In this clinical setting, given the patients ongoing pain despite a lengthy conservative treatment plan, the requested service is medically indicated. Therefore, an MRI of the left foot is medically necessary for the evaluation of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

A 64-year-old female enrollee has requested Ampligen for treatment of her chronic fatigue syndrome, myalgic encephalomyelitis and marked autonomic dysfunction. Findings:  Two physician reviewers found that chronic fatigue syndrome may also be referred to as post-viral fatigue syndrome (PVFS, when the condition arises following a flu-like illness), myalgic encephalomyelitis (ME), or several other terms. The cause or origin of CFS is currently unknown, and there is no diagnostic laboratory test or biomarker. Ampligen is an experimental drug that has been studied for the treatment of AIDS and CFS. A controlled clinical study in 92 patients with CFS was performed in 1994 (see Strayer and colleagues). The FDA concluded that the trials to date have not provided confirmatory evidence of the efficacy of Ampligen. Therefore, treatment with Ampligen for viral illnesses remains the subject of debate. In addition, there remain safety concerns relating to the toxicity of Ampligen with escalating dosages. There is a FDA clinical trial of Ampligen for CFS in progress but results have not been published to date. Phase III data regarding the safety and efficacy of Ampligen is needed before the appropriateness of Ampligen in this setting can be established.
Appeal type: Experimental/Investigational
Decision: Overturned

An enrollee has requested authorization and coverage for magnetic resonance imaging (MRI) of the breast. The medical records document that this patient has a BRCA positive test results. Based on current guidelines from the National Comprehensive Cancer Network (NCCN), an annual MRI screening with contrast is recommended for further evaluation of patients with BRCA mutations. MRI with contrast is the most sensitive noninvasive screening method for detection of breast cancer in high-risk female patients and has been validated for those with BRCA mutations. Bilateral breast MRI with contrast has been established as the standard of care as the recommended screening method for breast cancer detection for women with BRCA mutations. For these reasons, the requested MRI of the breast is likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Findings:  Three of the three physician reviewers found the requested MRI of the breast is likely to be more beneficial for evaluation 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 evaluation 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 internal medicine with subspecialty certifications in medical oncology and hematology and is actively practicing. Physician reviewer 2 is board certified in internal medicine with subspecialty certification in medical oncology and is actively practicing. Physician reviewer 3 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 50-year-old male enrollee requested a PET/CT scan for evaluation of his colon cancer.  Findings:  Three physician reviewers found that this patient has a history of stage IV colon cancer and is currently undergoing treatment with chemotherapy.  Clinically, the patient is stable.  PET studies for patients with a history of colon cancer have been shown to be useful in the initial staging, to evaluate initial response to chemotherapy, for re-staging following completion of chemotherapy and/or radiation therapy, and to evaluate for suspected recurrent disease.  A review of the peer-reviewed literature found insufficient support for the use of PET scans for surveillance of patients in this clinical situation.  The National Comprehensive Cancer Network guidelines do not recommend PET scans for evaluation of response to chemotherapy. At this time, there is insufficient clinical evidence to support the requested PET/CT scan so the PET/CT scan is not likely to be more efficacious than other methods of evaluating this patient.