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

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for monthly occipital nerve block injections.Findings: Two out of three medical experts decided that monthly occipital nerve block injections are likely to be more beneficial for you than any available standard therapy.Researchers indicated that occipital nerve block as adjunctive therapy has shown safety and efficacy in treating patients with migraines, measured by the reduction in pain. Additionally, another study demonstrated that greater occipital nerve (GON) block intervention is able to significantly reduce pain intensity and analgesic medication consumption in migraine patients. Moreover, other research states, Conservative therapeutic approaches are considered first-line. Anesthetic nerve blocks may have a dual role in both supporting diagnosis and providing pain relief. Newer minimally invasive procedures, such as pulsed radiofrequency (PRF) and occipital nerve stimulation (ONS), represent an exciting therapeutic avenue for severe/refractory cases. Surgical interventions should be reserved for select patient populations who have failed all other conservative and minimally invasive options, to be weighed against potential risk. Another study indicates, Occipital nerve block is often the initial treatment of choice for occipital neuralgia as it can potentially be both diagnostic and therapeutic. Alternative or adjunctive local and oral agents are used in patients who report partial or transient benefit from occipital nerve blocks. The author also states, The procedure can be repeated when pain recurs. A review by the American Headache Society recommended at least three-month interval between injections if corticosteroids are used.In this case, the patient has been diagnosed with occipital neuralgia, which has been unresponsive to numerous medications in many different categories. Additionally, documentation indicates that occipital nerve blocks have improved pain, improved function, and reduced the number and severity of headaches. Furthermore, guidelines support repeat injections when pain recurs. Therefore, requested monthly occipital nerve block injections are likely to be more beneficial for treatment of the patients condition than any available standard therapy.Final Result: The reviewers determined that the requested services are likely to be more beneficial than any available standard treatment for the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer 1 and reviewer 3 are board certified in anesthesiology with sub-specialty certification in pain medicine. Reviewer 2 is board certified physical medicine and rehabilitation with sub-specialty certification in pain medicine. All reviewers 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: Overturned

A 37-year-old male enrollee requested authorization and coverage of the medication Hepsera. The Health Plan denied the request indicating that the requested medication is not medically necessary for the treatment of the enrollees hepatitis B.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plans denial on the basis that the requested medication is medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

A 32-year-old female enrollee has requested acute inpatient psychiatric treatment at Palomar Medical Center for the treatment of her behavioral health problems. Findings:  The physician reviewer found that the submitted clinical evidence demonstrates this patients admission was prompted by deterioration in poor self-care due to non-adherence to her psychiatric treatment (with resultant psychosis). This exacerbation of her paranoia and hallucinations resulted in her not eating or caring for herself and her unborn fetus  and led to her being detained into an inpatient setting for both her safety and the well being of her unborn fetus. While she showed ongoing limited insight into her psychiatric symptoms, the submitted documentation indicates that the patient responded to treatment and was compliant with treatment (including medications and frequent fetal monitoring). She also was allowed to sign for her own medical procedures. Additionally, she had no evidence of dangerous behaviors during the period under review. Furthermore, she was accepting of medications during the disputed period and was described as responding to that treatment by her community nurse. All told, the submitted evidence demonstrates the patient could have been treated in a less restrictive setting during the period at issue.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Harvoni for medical treatment of her hepatitis C.  Findings:  Three physician reviewers found that per the American Association for the Study of Liver Diseases and Infectious Diseases Society of America, the medical evidence supports treatment of all patients with chronic hepatitis C, except those with limited life expectancy less than 12 months due to non-liver-related comorbid conditions.  Treating patients with early stage disease may help avoid untoward complications from advanced disease, including liver failure and extrahepatic complications from advanced disease.  All told, the requested Harvoni is medically indicated for the treatment of this patient.  Final Result:  Three reviewers have 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:  All three reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition, knowledgeable about the proposed treatment, and familiar with guidelines and protocols in the area of the treatment under review.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for corneal collagen cross-linking procedure.Findings:  Three physician reviewers found that this patient was diagnosed with progressive keratoconus. The records document decreased visual activity which interferes with activities of daily living. Keratoconus is caused by a structural abnormality in the collagen of the cornea, wherein the cornea becomes progressively misshapen over time. Eventually, this may develop into failure of the cornea, with intractable edema and permanent loss of vision. The classic treatment for keratoconus-induced visual decline is a corneal transplant. This procedure has the potential for significant complications. Corneal collagen cross-linking has been studied extensively and is considered the standard of care for patients with progressive keratoconus. As compared to corneal transplant, corneal collagen cross-linking involves less risk. Therefore, corneal collagen cross-linking procedure was likely to have been superior over other treatment options. Final Result: The reviewers determined that the services at issue were 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 reviewers 1, 2 and 3 are board certified in ophthalmology 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for mobile cardiac outpatient telemetry (MCOT) device for 30 days for treatment of the enrollees chest pain. Findings:  The physician reviewer found that based on the records provided the patient presents with palpitations that are not further characterized in the records provided. In this circumstance, if additional evaluation for a dysrhythmia is indicated then prolonged serial 48-hour Holter monitoring or off-line self-activated or auto-triggered cardiac event monitoring is sufficient in recording cardiac rhythm during symptoms. There is no documentation to indicate that these devices have been tried and failed for evaluation of the patients current symptoms.  Current expert consensus guidelines endorsed by national organizations also consider Holter monitoring and/or patient-activated or auto-triggered event recorders appropriate initial tests and standard of care for evaluation of dysrhythmias. Continuous real-time monitoring by telemetry services is not medically necessary in this case, since off-line analysis of a patient-activated or auto-triggered event recorder is sufficient in the identification of dysrhythmias during symptoms without jeopardizing patient safety. Immediate recognition and reporting of dysrhythmias through a call center provided by real-time mobile telemetry services is not medically necessary and has not been shown to improve health outcome compared to standard monitoring techniques. For the reasons provided, the request for MCOT device for 30 days has not been established as medically necessary for the treatment of the patients medical condition.  Final Result: The reviewer determined that the requested device 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 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: Upheld

A 48-year-old female enrollee requested authorization and coverage of physical therapy. The Health Plan denied the request indicating that the requested therapy was not medically necessary for the treatment of the enrollees neck, head, and back pain.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested therapy is not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Harvoni for treatment of his chronic hepatitis C virus genotype 6. Findings: Two physician reviewers 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, regardless of fibrosis, should be treated except those with a limited life expectancy due to non-liver-related comorbid conditions. For treatment naive patients with genotype 6 hepatitis C, the AASLD/IDSA guidelines recommend treatment with Harvoni for 12 weeks. This regimen is based on in vitro data as well as clinical trials showing 92% sustained virologic response in this patient population. Final Result: Two reviewers 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 three reviewers 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: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:   The parent of an enrollee has requested residential treatment services with specific patient/physician ratios for treatment of the enrollees behavioral health condition.  Findings:  The physician reviewer found that while the medical literature regarding staff to patient ratios for adolescents who are receiving residential treatment services is somewhat limited, studies clearly show that higher staff to patient ratios are overall much more effective. Studies have shown that retention rates were greater in facilities that reported a higher staff to patient ratio and that individual consultation and high staffing levels were both associated with retention. These studies also indicated that the amount of programming implemented at these facilities was directly correlated with the number of staff available to run the groups or programs. Although the absolute number of staff was not delineated as a measure of effective mental health treatment, it is clear that the amount of direct attention provided by staff members to patients was strongly correlated with better patient outcomes and reduction in recidivism.  Additionally, there are ample studies suggesting, and it is well established from the literature, that medication management alongside therapy is consistently much more effective. A program which includes a team based approach including a prescriber as well as highly trained therapist will be more effective. This patient has strong documented history of suicidal ideation and behavior (SIB) as well as severe anxiety and post-traumatic stress disorder (PTSD).  Moreover, the records indicate that the patient continues to be suicidal. Therefore, the requested services are medically necessary for treatment of this patients SIB; severe anxiety and panic disorder; and PTSD.   Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: The reviewer is board certified in psychiatry with sub-specialty certification in child and adolescent 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: Overturned

A 34-year-old female enrollee has requested Botox therapy for treatment of her hyperhidrosis.  Findings:  The physician reviewer found that the severity of this patients symptoms will improve with Botox therapy.  In addition, the patients daily functioning will improve with Botox therapy. Furthermore, there is evidence to support the safety and efficacy of Botox therapy in the treatment of severe hyperhidrosis.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential treatment center services for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found that the patient presented with post-acute withdrawal symptoms. However, there was no evidence demonstrating that she was at risk to self or others. She was medically and psychiatrically stable. She demonstrated impulsivity with a recent history of detoxification and immediately relapsing.  This was compounded by the fact that she had recently undergone a double mastectomy due to breast cancer, causing additional depression, anxiety, and stress. In this clinical setting, the risk for relapse is increased and residential treatment was medically necessary. At the beginning of treatment she was isolative, however she became more motivated and engaged. She was described as attentive, engaged and actively sharing. She could have been stepped down to a lower level of care. Final Result: The reviewer determined that a portion of the services at issue were 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: Experimental/Investigational
Decision: Overturned

A 54-year-old female enrollee has requested coverage for Camptosar chemotherapy for treatment of her breast cancer with bone metastases.  Findings:  Two physician reviewers found that the use of Camptosar in stage IV breast cancer is not on the FDA label, so one must rely on the current medical literature (Cobleigh). A multi-center phase II clinical study tested a weekly and every 3 week regimen of Camptosar in metastatic breast cancer. The authors concluded that overall the drug was well tolerated, safe and the weekly regimen resulted in a 23% objective response rate (Perez, et al). These findings support the requested off-label use for Camptosar in this patient who has exhausted the standard treatment options.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: A female patient has requested authorization and coverage for acupuncture. The Health Plan has denied the request, indicating this treatment is experimental or investigational for the enrollees medical condition.At issue is whether acupuncture is likely to be more beneficial for treatment of the patients condition than any available standard therapy. Acupuncture is not a common therapy for the management of trochanteric bursitis. While medical literature indicates that needling is not inferior to cortisone injections in the treatment of GTPS, the literature does not demonstrate a clinical difference or advantage to needling in the treatment of this condition. In this context, it is unlikely that acupuncture would result in a more beneficial outcome for the patient. Therefore, acupuncture is not likely to be more beneficial than any standard therapy to treat the patients medical condition.Final Result: All three reviewers have determined the requested acupuncture services are not likely to be more beneficial than any available standard therapy to treat the patients medical condition. The Health Plans denial for the acupuncture services should be upheld.Credentials/Qualifications:  Reviewer #1 is a is board certified licensed M.D., board certified in oriental medicine, reviewer #2 and #3 are both a licensed D.C., L.Ac., board certified in chiropractic care and oriental medicine and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 23-year-old female enrollee has requested reimbursement for tilt table testing for evaluation of the enrollees syncope. Findings:  The physician reviewer found that based on the records provided, the patient had a history of cardiac ablation for an arrhythmia and presented with three syncopal episodes, each with an identifiable trigger, such as pain or high fever. Though the syncopal episodes had some features that are suggestive of a neurocardiogenic cause, such as the triggers mentioned, there were also some atypical features, such as the sudden onset of syncope without any warning signs.  In this setting when neurocardiogenic (reflex) syncope is suspected but the presentation is atypical, tilt table testing is considered a reasonable and appropriate test.  This patient, in particular, had a possible primary arrhythmic cause given her prior history of arrhythmia that was ablated. Current guidelines, which are endorsed by several national organizations, also consider tilt table testing appropriate in patients to help confirm a diagnosis of neurocardiogenic (reflex) syncope when the diagnosis is suspected but not confirmed by historical evaluation alone (Brignole and Hamdan; and Moya, et al.). As such, the diagnostic testing at issue was appropriate and medically necessary for evaluation of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An requested reimbursement for the Afirma Gene Expressions Classifier (GEC). Findings:  The physician reviewers found that the risk of malignancy is 5-15% in a follicular lesion of unknown significance. The Bethesda System recommends a repeat biopsy for this type of nodule. In this case, the patient had a repeat biopsy. The second biopsy also resulted in FLUS. The American Thyroid Associations guideline suggest that for nodules with FLUS cytology, investigations such as repeat FNA or molecular testing may be used to supplement malignancy risk assessment in lieu of proceeding directly with a strategy of either surveillance or diagnostic surgery. In this case, the result of the Afirma GEC was suspicious for malignancy. In addition, the BRAF gene mutation analysis was done, with negative results. This information was important to determine the extent of surgery. A benign Afirma test result could have prevented an unnecessary surgery and observation can be safely continued. For these reasons, the Afirma GEC provided was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: 3 of 3 reviewers determined that the testing 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 reviewer number one is board certified in internal medicine with sub-specialty certification in medical oncology and is actively practicing. Physician reviewer numbers two and three are board certified in internal medicine with sub-specialty certification in endocrinology, diabetes, and metabolism and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a nine-year-old male enrollee has requested individual speech therapy for treatment of the enrollees autism. Findings:  The physician reviewer found that the literature strongly supports that it is medically necessary for this autistic patient to receive speech therapy. Although the patient has only minimally benefitted from speech therapy in the past, as noted above, this does not preclude him from benefitting from speech therapy in the future. Based upon the documentation provided, this patient should receive two hours per week of individualized speech therapy for six months. If upon re-evaluation, he shows improvement, speech therapy should be continued for an additional six months.