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

Nature of Statutory Criteria/Case Summary:  An enrollee has requested AmniSure rupture of membranes (ROM) test for evaluation of her contractions with fluid leakage. Two physician reviewers found that according to the American College of Obstetricians and Gynecologists (ACOG), AmniSure testing has been recommended as an adjunct to standard assessment of pooling, ferning and nitrazine testing of vaginal fluid when these tests are inconclusive. AmniSure is not recommended as a first-line test. One prospective study has found placental alpha-microglobulin-1 in cervicovaginal secretions is superior to conventional clinical assessment in the diagnosis of rupture of membranes and a second study reported it to be highly accurate in diagnosing fetal membrane rupture. However, other studies have noted false-positive test result rates of 19-30% in patients with clinically intact membranes and symptoms of labor. This patient did not have inconclusive standard testing before the AmniSure test since both ferning and nitrazine were negative. Thus, the AmniSure ROM test was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: Two 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: All three reviewers are board certified in obstetrics and gynecology 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

A 50-year-old female enrollee requested authorization and coverage of myofascial release therapy. The Health Plan  denied the request indicating that the requested therapy is not medically necessary for treatment of the enrollees myofascial pain syndrome.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

A 37-year-old male enrollee requested authorization and coverage of the medication Clomid. The Health Plan denied the request indicating that the requested medication is not medically necessary for the treatment of the enrollees hypogonadotropic hypogonadism.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 35-year-old female enrollee has requested genetic testing for evaluation of her dilated cardiomyopathy. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested testing.  This patient received chemotherapy for treatment of breast cancer and subsequently was diagnosed with a cardiomyopathy. Some chemotherapy used to treat breast cancer is known to cause cardiomyopathy.  The records reference an echocardiogram obtained prior to initiation of chemotherapy.  Thus, there is a possibility that the chemotherapy she received was potentially cardiotoxic.  Moreover, a clinic note documents that her cardiomyopathy was likely related to chemotherapy.  Per the submitted records, there are no documented first-degree relatives with cardiomyopathy.  Therefore, testing for gene defects associated with cardiomyopathy is not medically necessary and is not considered standard accepted practice in the medical community.  All told, the requested genetic testing is not medically indicated for the evaluation of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

A 64-year-old male enrollee has requested for vision therapy for treatment of his vision deficits status post stroke. Findings:  Three physician reviewers found that the American Academy of Ophthalmology states, there is little evidence-based information supporting the effectiveness of vision therapy. The limited data that is available is highly subjective and has not been repeated by independent observers. Although this patient has an organic visual deficit as a result of his stroke, there is no evidence that vision therapy will materially correct that deficit. Evidence confirming the effectiveness of vision therapy for patients with a visual field deficit is lacking and the currently available studies do not provide adequate evidence that vision therapy will be advantageous for this patient.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for mouth guard/oral appliance. Based on the provided documentation and the available peer-reviewed medical literature, the utilization of an oral orthotic appliance for this patient is not supported as medically necessary. As noted on the patients magnetic resonance imaging (MRI) study, the condylar heads, articular discs, and articular fossa were found to be in normal relationship and function, with the typical movements observed. Further, the records dated in April do not document that other treatment modalities typically attempted for patients with jaw pain such as including medications, exercises, food avoidance, or a basic dental guard for balancing of occlusion. In combination, these modalities have shown to be effective and with excellent long-term outcomes. The treating provider is fabricating an orthotic device that fits on the occlusal surface of the teeth in order to reposition the temporomandibular joint disc and glenoid fossa relationship. This is different from an occlusal guard. The requested device has not been established as medically necessary to treat the provided conditions, especially not as a first-line treatment before clinical attempts at using other modalities. For these reasons, the requested mouth guard/oral appliance is not medically necessary for treatment of this patient. 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 licensed D.D.S., board certified in dentistry, 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 56-year-old female enrollee has requested for minimally invasive bunion surgery for treatment of her bunions on the left and right feet. Findings:  The physician reviewer found that review of the relevant literature reveals that minimally invasive bunionectomy techniques are not considered standard of care, and have limitations as to how much correction they can provide. There is a lack of scientific evidence demonstrating that bunion surgery performed via minimally invasive techniques results in a better outcome than standard surgical intervention. As such, the requested procedure is not medically necessary for treatment of the patients condition.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 5-year-old male enrollee has requested coverage for 6 months of applied behavioral analysis (ABA) therapy for treatment of the enrollees disorder of childhood or adolescence, not otherwise specified (NOS). Findings:  The physician reviewer found that applied behavioral analysis has been shown to be effective in treating behaviors associated with autism spectrum disorder. Treatments based on operant principles of learning are more effective in reducing maladaptive behaviors than alternative treatments. A paper by Warren and colleagues reviewed 34 studies of early intervention in autism and concluded that studies of Lovaas-based approaches as well as early intensive behavioral intervention variants and the Early Start Denver Model resulted in some improvement in cognitive performance, language skills, and adaptive behavior skills (Warren, et al.). Treatment intensity may play an important role and ABA therapy must be implemented at a sufficient intensity in order to provide optimal outcomes (Kelley, et al. and Granpeesheh, et al.). Although the most significant gains are made after one year of ABA therapy when compared to controls, further gains have been noted in subsequent years of therapy (Sallows, et al.). Additionally, many studies have noted improvement of function in older children with autism spectrum disorders, with the use of intensive ABA therapy (Sallows, et al.) The goals for older children are often to identify and remediate particular deficits, such as non-compliance, elopement and tantrums with this patient. The requested duration of therapy is medically reasonable and appropriate for this patient based upon his documented deficits. Thus, it is medically necessary that this patient receive six months of ABA therapy.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a dopamine transporter single photon emission computed tomography (DaT-SPECT) scan of the brain. Findings:  Two physician reviewers found that the peer-reviewed medical literature, noted that DaT-SPECT scan has the potential to provide support in diagnosis, especially for those patients who have an unclear presentation of Parkinsonian syndrome. Another study found that DaT-SPECT scan imaging significantly affected the clinical management and diagnosis of patients with clinically uncertain parkinsonian syndrome (CUPS). The authors concluded that DaT-SPECT scan is safe and well-tolerated and is a useful adjunct to differential diagnosis of CUPS. Further, the study reported that DaT-SPECT may help differentiate essential tremor (ET) from parkinsonian syndrome (PS) as an adjunct to other diagnostic evaluations. Thus, the literature does support the use of DaT-SPECT scan to assist in the diagnosis and help guide treatment decisions in patients with suspected parkinsonian syndromes. Final Result: Two reviewers determined that the requested diagnostic procedure is 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 physician reviewers 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 50-year-old male enrollee has requested for back surgery for treatment of his low back pain and left leg pain. Findings:  The physician reviewer found that the current medical evidence does not support the requested procedure in this clinical setting.  Non-radicular low back pain associated with common degenerative changes is effectively treated with intensive rehabilitation rather than fusion.  The key to obtaining favorable surgical outcomes is careful patient selection.  When an established indication, such as spondylolisthesis, is present, fusion may result in improvement.  However, less improvement is expected with patients with chronic low back pain.  Diffuse low back pain without an explainable functional deficit or other pathological process is not an indication for surgery.  Surgical treatment of back pain associated with multilevel disc degeneration seen on MRI images has a poor success rate.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for magnetic resonance imaging (MRI) of the lumbar spine.The first appropriate imaging for the evaluation of low back pain with radicular symptoms is lumbar radiographs. According to American College of Radiology (ACR) Appropriateness Criteria for low back pain, if pain persists after four to six weeks of conservative management, and the patient is a surgical or intervention candidate, then MRI of the lumbar spine is the usually appropriate next exam. In this case, there is no documentation of four to six weeks of conservative management, which would include physical therapy, NSAIDs or exercise. The patient's initial physical therapy consultation was less than three weeks ago. There is also no documentation of radiographs of the lumbar spine. Under these circumstances, the requested magnetic resonance imaging (MRI) of the lumbar spine is not medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested services are not medically necessary to treat the patient's 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: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Yasmin for treatment of the enrollee, who reports a history of menstrual pain.Findings:  The physician reviewer found that there is no documentation that this patient has failed a trial of generic oral contraceptive pills that are specifically of the same formulation as Yasmin. Failing other oral contraceptive pills or generics of other pill formulations is not comparable.  There are many different formulations of oral contraceptive pills, each with a varying combination of estrogen and progestin. Specifically, Yasmin is drospirenone/ethinyl estradiol. In this case, the Health Plan has offered the patient several different alternatives to Yasmin which in and of themselves are appropriate equivalents. All oral contraceptive pills are acceptable to help treat patients presenting with the medical condition of dysmenorrhea. Oral contraceptive pills are typically used in conjunction with other management options, such as nonsteroidal anti-inflammatory medications, and can be very effective in controlling menses and the associated pain symptoms some women experience. Generic oral contraceptive pills approved by the U.S. Food and Drug Administration have been shown to be bioequivalent and pharmaceutically equivalent to the branded product and are interchangeable. In this patients case, the submitted records do not document that the patient has had a trial of a similar estrogen/progestin combination as a generic. The Health Plans list of alternative oral contraceptive pills are appropriate options. Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in obstetrics and gynecology 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

The parents of a two-year-old male enrollee requested authorization and coverage of an umbilical cord blood transplant for the treatment of sanfilippo syndrome type A.  The health plan denied the enrollee's request indicating that the requested treatment is experimental.Three physician reviewers performed an experimental/investigational Independent Medical Review.  All three physician reviewers determined that the requested treatment is not likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy; therefore, the review organization upheld the health plan's denial.
Appeal type: Experimental/Investigational
Decision: Upheld

A 52-year-old male enrollee has requested for Stereotactic Radiation Therapy (CyberKnife) with fiducial (seed) placement for treatment of his prostate cancer.   Findings:  Three physician reviewers found that external beam radiation has been studied and found overall to have similar success in treating patients when compared to surgery. Surgery and radiation have their own advantages and disadvantages. Prostate cancer is not the same condition in every patient, one large classification is based on Gleason Score, which is a numbering system ranging from 2 to 10 with the lower numbers generally being a slower growing tumor. In order to determine the success of treating prostate cancer, there must be a long follow-up as the tumor biology may be a slow growing tumor. The studies for CyberKnife lack adequate follow-up to assess the overall success in treating prostate cancer. Randomized trials are also lacking.
Appeal type: Medical Necessity
Decision: Upheld

A 60-year-old female enrollee has requested coverage for Tracleer for treatment of her right heart failure and pulmonary hypertension. Findings:  The physician reviewer found that Tracleer is indicated only for symptomatic patients with WHO Group I pulmonary hypertension (i.e. pulmonary hypertension that is idiopathic, familial, associated with HIV, associated with connective tissue diseases or associated with congenital systemic-to-pulmonary shunts).
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for inpatient hospital services. Per the American Society of Addiction Medicine (ASAM) criteria, this patient met Level 4 criteria for inpatient hospital services for a portion of the admission. According to the ASAM guidelines, the patient continued in withdrawal management at the appropriate level until his withdrawal signs and symptoms were sufficiently resolved such that he was stable for transfer to less intensive level of care. The first day of the Health Plans denial, the patient still required Level 4 monitoring for withdrawal management. He was on his third day of phenobarbital taper and still required lorazepam as needed. He was also still on intravenous fluids on this date. His pulse ranged from 93-109.  The patient reported that he was unable to walk without a walker due to phenobarbital and was provided with an assistive device. Thus, the first day of inpatient hospital services were medically necessary for this patient. However, by the next day, the patient was no longer in uncontrolled alcohol withdrawal and he had stable vital signs without reports of confusion or altered mental status. The patient was treated for severe withdrawal with improvement. He was having some difficulty coping with withdrawal discomfort. He was on oral medications and was being tapered off phenobarbital. The patient no longer required lorazepam to control his withdrawal. The patients lab abnormalities were consistent with alcohol use disorder that including mild hyponatremia and thrombocytopenia. The records do not document the presence of severe medical problems that required 24-hour medical and nursing care. The patient was found to be thrombocytopenic, mildly hyponatremic, and had elevated aspartate aminotransferase (AST). He reported that his ambulation was problematic while on phenobarbital. There were no other medical co-morbidities. The patient had complaints of anxiety. He was not suicidal, homicidal, or psychotic. He did not have any reported behavioral problems. Per ASAM, a patient who meets criteria in dimensions 1, 2, or 3 is appropriately placed in a Level 4 program. As this patient did not meet the criteria in dimensions 1, 2, or 3, the inpatient services from were not medically necessary per the ASAM guidelines. Given these findings, a portion of the inpatient hospital services were medically necessary for this patient. Final Result: The reviewer determined that a portion of the services at issue was medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned. Credentials/Qualifications: The reviewer is board certified in psychiatry with subspecialty certification in addiction medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 44-year-old male enrollee has requested prescription medication Lyrica for treatment of small-fiber neuropathy.  Findings:  The physician reviewer found that while Lyrica is specifically approved for diabetic neuropathy, it is also useful for a number of different painful neuropathies. Treatment with Lyrica is commonly prescribed for patients such as this patient, as it is known to be safe and effective.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for DecisionDx-Melanoma assay performed for evaluation of the enrollees malignant melanoma. Findings:  The physician reviewer found that DecisionDx-Melanoma assay tests the tissue genetics of the melanoma and can stratify whether a melanoma is high risk for metastasis or not. The test examines gene markers and then the lesion can be further stratified to tell if it is high risk for metastasis. This test has shown some accuracy determining risk of metastasis; however, decision-making based on the results of the test is indeterminate at this time. There is limited scientific evidence permitting conclusions concerning the effect of this test on health outcomes and there is not enough published data to support its routine use. The treatment of this patient would not change based on the results of the examination. Moreover, the test is not considered standard of care for treatment of patients in this clinical setting. Formal standard procedures or precautions that would be changed in light of the data is lacking. The current standard of care would be to perform a wide local excision. Since this test does not provide a superior benefit over established tests in terms of outcomes, DecisionDx-Melanoma test gene assay was not likely to have been more beneficial for the evaluation of this patients medical condition than any available standard modalities. Final Result: All three reviewers determined 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:  All three reviewers are board certified in dermatology 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.