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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for magnetic resonance imaging (MRI) of the pelvis. The submitted documentation supports the medical necessity of the requested service. Hip pain is a common and disabling condition that affects patients of all ages. The causes of hip pain depend on the location, such as the anterior hip and groin, the posterior hip and buttock, or the lateral hip. Anterior hip and groin pain may be due to osteoarthritis, hip labral tears, or may be radicular from the upper lumbar spine. Posterior hip pain is associated with piriformis syndrome, sacroiliac joint dysfunction, lumbar radiculopathy, or may be localized to a tumor mass. Lateral hip pain occurs with greater trochanteric bursitis or femoroacetabular impingement. Clinical examination tests, although helpful, are not highly sensitive or specific for most diagnoses. X-rays do not always show the pain source. MRI may show occult traumatic fractures, stress fractures, and osteonecrosis of the femoral head. MRI of the pelvis is useful for the diagnosis of rectal pain. It has an accuracy of 95% in the detection and localization of deep endometriosis. The current medical evidence supports the requested service in this clinical setting. Therefore, the requested MRI of the pelvis is medically necessary for the evaluation of this patient.Final Result: The reviewer determined that the requested service is medically necessary for evaluation 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: Upheld

A forty year-old male who has been diagnosed with chronic pain syndrome and post-laminectomy syndrome is requesting authorization for spinal cord stimulator implantation.Reviewers Findings:  The reviewing physician found that spinal cord stimulator implantation is not medically indicated at this time. This procedure has not been proven to improve functionality for patients with chronic pain.  The reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

Representatives of an eight-year-old male enrollee  requested authorization and coverage of the medication Humatrope for the treatment of a long-term history of short stature. 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 overturned the health plans denial on the basis that the requested prescription is medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for DecisionDx-Melanoma genetic testing. The National Comprehensive Cancer Network (NCCN) guidelines recommendation for treatment of a stage 1a melanoma is wide local excision. In this case, the patients melanoma, Breslow depth of 0.45 mm, was clinically stage 1A, without high-risk features such as ulceration. The DecisionDx-Melanoma result classified her risk of recurrence as Class 1a, the lowest risk of recurrence at five years. Given that the patients melanoma was superficial without high risk features, pathologic staging procedures may have been used for prognostication, and the results of the testing did not affect the course of the patients treatment. Therefore, the DecisionDx-Melanoma genetic testing was not likely to have been more beneficial than any other available standard therapy for the patients medical condition.Findings:  Three of the three physician reviewers found the requested DecisionDx-Melanoma genetic testing was not likely to have been more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested service was not likely to have been more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewers 1, 2, and 3 are board certified in dermatology 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

The parent of a 10-year-old male enrollee has requested occupational therapy including sensory integration techniques for the treatment of the enrollees Aspergers syndrome. Findings:  The physician reviewer found that sensory integration is a widely used intervention in occupational therapy. Pfeiffer and Kinnealey presented at the American Association of Occupational Therapy Associations Annual Conference in 2008 with findings of their double-blind study that children with autism who received sensory integration therapy through occupational therapy had a modest but significant decrease in displaying autistic mannerisms. Schaaf and Miller also discuss sensory integration as it is used in occupational therapy practice for young patients with developmental disabilities. A treatment plan based on sensory integration theories and techniques is appropriate in this setting given this patients deficiencies in his personal sensory system including limited awareness of body and failure to grasp the concept of personal space and sensory issues with food.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Harvoni 90-400 mg for 12 weeks for treatment of the enrollees hepatitis C. Findings:  The physician reviewer found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America, all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. The guidelines recommend that all patients should be treated, regardless of fibrosis stage.  Per the guidelines, non-cirrhotic, treatment-naive, genotype 1 patients should be treated with Harvoni for 12 weeks or Zepatier for 12 weeks, and the medications are U.S. Food and Drug Administration (FDA) approved for all patients with chronic hepatitis C, genotype 1 regardless of fibrosis stage.  The guidelines recommend either Harvoni or Zepatier as acceptable therapy.  There is a need for NS5A resistance testing prior to Zepatier in genotype 1a.  No medical contraindication to Zepatier is reported in this case.  Thus, although treatment of hepatitis C is needed, the medical necessity of Harvoni 90-400 mg for 12 weeks has not been established. Final Result: The reviewer determined that the requested medication regimen 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 gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a hospital bed, total electric with head, foot, and height adjustments, including side rails and mattress (HCPCS code E0265). Naddaf and colleagues describe inclusion body myositis as characterized by progressive asymmetric weakness predominantly affecting the quadriceps and/or finger flexors, with loss of ambulation and dysphagia as major complications of the disease. Aggarwal and Oddis report that there is no standard course of treatment for management of inclusion body myositis and that therapies are symptomatic and supportive. In this case, the patient has quadriplegic weakness with recent decline and generalized proximal and distal weakness. His quadriplegic weakness has progressed to the point that he is incapable of safe transfers to and from his bed to his wheelchair without the bed being raised to an elevated position. As he is unable to sit up on his own without assistance, he is at increased risk for aspiration pneumonia and pressure ulcers. Given that supportive management of this patients condition includes adaptive equipment, physical therapy, and home modifications if and as needed with the goal of functional independence and safety, the requested equipment is medically indicated. Therefore, a hospital bed, total electric with head, foot, and height adjustments, including side rails and mattress (HCPCS code E0265) is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested equipment 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 physical medicine and rehabilitation with sub-specialty 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: Medical Necessity
Decision: Overturned

The parent of a four-year-old male enrollee has requested coverage for speech therapy for treatment of the enrollees autism. Findings:  The physician reviewer found that, as noted by and Pickett and colleagues, early studies of patients with autistic spectrum disorder (ASD) initially reported a poor prognosis for the future development of speech in nonverbal patients, but there is newer evidence that these patients may develop useful speech with appropriate therapy. In patients with ASD, laryngeal or oropharyngeal anatomical abnormalities are not necessary for abnormal language development or abnormal motor behaviors to persist. The scientific data suggests that the plasticity of the developing brain enables the retraining of neural circuitry not compromised by the underlying pathogenetic processes that give rise to ASD including speech and language delay. Thus, despite the presence of an underlying neurologic disease in patients with ASD, there is evidence demonstrating that speech therapy in an individualized setting can have a positive outcome on development of useful speech.
Appeal type: Medical Necessity
Decision: Upheld

A 39-year-old female enrollee has requested a laparoscopic hysterectomy for treatment of her pelvic and back pain.   Findings:  The physician reviewer found that based upon the submitted documentation, the patient has a significant history of abnormally heavy bleeding and pelvic pain. There is evidence of an endometrial mass and other abnormalities on pelvic ultrasound. In patients with abnormal uterine bleeding and imaging evidence of endometrial lesions, structural causes must be evaluated before management of the abnormal uterine bleeding is recommended. Diagnostic techniques within the standard of care include endometrial sampling by dilation and curettage with hysteroscopy. There is no evidence in the submitted records that the patients endometrial cavity was evaluated prior to the recommendation of laparoscopic hysterectomy. Further, based upon the records provided, the patient has not undergone a trial of medical therapy. Therefore, clinical indications for laparoscopic hysterectomy have not been established. As such, the requested service is not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 52-year-old man with bilateral knee arthritis. He has received Synvisc injections in the past with good results. His most recent course of Synvisc was administered in October 2005. A request has been made for reimbursement for these injections as well as prospective authorization for a series of Synvisc injections every six months. The Health Plan has denied this request indicating that Synvisc injections are not medically necessary for treatment of the patients medical condition.The patient is relatively young for knee replacement surgery. He has had no relief with cortisone or medications. The submitted clinical evidence indicates the patient has had a good response to Synvisc in the past. There was no contraindication to the series of Synvisc injections the patient received in October 2005 and it appears the patient benefited from the injections. However, there is no evidence that Synvisc injections every six months are useful for treatment of arthritis of the knee. Therefore, prospective authorization of twice yearly Synvisc injections is not medically appropriate or indicated. Based upon the information set forth above, I have determined although the Syvnisc injections the patient received in October 2005 were medically necessary, Synvisc injections every six months are not medically necessary. Therefore, the Health Plans denial should be partially overturned.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: A 59-year-old female enrollee has requested authorization and coverage for Estradiol 0.01% cream/appl. This patient has vaginal symptoms secondary to menopause and tissue atrophy due to estrogen deficiency. The standard treatment for this condition is estrogen therapy. The route of delivery is variable and depends on the patient. In this case, there is no documentation that the patient could not tolerate or did not respond to the preferred formulary treatment options, including generic Vagifem. Thus, the requested Estradiol 0.01% cream/appl is not supported as medically necessary for treatment of this patients medical condition. 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: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement and prospective authorization and coverage for residential treatment in a locked facility. The submitted documentation supports the medical necessity of the services at issue. The American Academy of Child and Adolescent Psychiatry and American Association of Community Psychiatrists Child and Adolescent Level of Care Utilization System is an important tool for determining the appropriate level of care for children and adolescents. In terms of risk of harm, the records support a score of 5. The patient continued to have suicidal ideation with intent and plan. In terms of functional status, the records support a score of 3. The patient has chronic deficits in interpersonal relationships. With regards to comorbidity, the records support a score of 3. The patient has comorbidities of major depressive disorder, posttraumatic stress disorder, and cluster b traits. The patient also has been experimenting with alcohol and marijuana. The patient did not have any medical problems which required 24-hour monitoring. With regards to environmental stress of the recovery environment, the records support a score of 4. The patients father was murdered. The patient has posttraumatic stress disorder from this incident and has not been able to process this. In terms of environmental support, the records support a score of 2. The patient has a supportive mother who is willing to participate in treatment. With regards to resiliency, the records support a score of 4. The patient was hospitalized three times in the prior month and continued to have suicidal thoughts with intent and plan and symptoms of depression. In terms of acceptance and engagement, the records support a score of 2. The patient is cooperative with staff and engages with treatment. Thus, the records support a composite score of 23. Based on these criteria, the patient meets criteria for continued residential treatment. Therefore, residential treatment in a locked facility was and is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the services at issue were and 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 expertise 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: Upheld

A 46-year-old female enrollee requested authorization and coverage of antibody tests, stool purges, metal toxicity tests, and hair analysis tests. The Health Plan denied the request indicating that the requested services are not medically necessary for treatment of the enrollees chronic fatigue 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 services are not medically necessary.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Oncotype DX testing for evaluation of the enrollees prostate cancer. Findings:  Two physician reviewers found that once prostate cancer is diagnosed in a pathologic specimen, risk stratification is performed by the analysis of certain features such as the grade of tumor and PSA level. This helps guide the most appropriate therapy for patients taking into account their age and co-morbidities because many patients will not require therapy and may be followed closely instead. The important features to recognize are Gleason score and PSA but these are imperfect. Thus, current biomarkers are inadequate for risk stratification and better prognostic biomarkers are needed. The Oncotype DX test is a gene expression analysis of target genes in the biopsy specimen that generates a genomic prostate score (GPS). A validation study was presented at the American Urological Association meeting in 2013 involving 395 patients. The GPS identified patients that had very low risk disease that could be followed rather than referred for surgery. Given that the current prognostic features are inadequate to make firm recommendations regarding active surveillance to patients, the Oncotype DX testing performed was medically appropriate and likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: The 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: Reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in medical oncology 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

A female enrollee has requested Harvoni for medical treatment of her hepatitis C virus genotype 1a.   Findings:  Three 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 limited life expectancy (less than 12 months) due to non-liver-related comorbid conditions.  Based on the provided records, published evidence of safety and efficacy in the published literature and clinical guidelines, the requested treatment with Harvoni should be approved as medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Butrans patch for treatment of the enrollee's pain.Findings:  The medical reviewer found that the submitted documentation supports the requested medication in this clinical setting.  This patient has tried multiple prior opiates, with only small decreases in pain scales.  She has had better results with Butrans patch.  According to the package insert, Butrans patch is indicated for chronic pain management as well as opiate maintenance therapy in patients with a history of opiate abuse.  This patient has tried multiple other medications, without adequate pain relief. She has also used other modalities, including physical therapy, behavioral therapy, and massage therapy. All told, Butrans patch 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 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: Upheld

A 65-year-old female enrollee has requested for skilled nursing facility level of care for treatment of her medical condition. Findings:  The physician reviewer found that the maximum rehabilitation potential at her current level of rehabilitation due to her NWB status on her left lower extremity. Her potential decline or deterioration can be prevented with a maintenance level of care which does not require skilled services, but can be accomplished with a rehabilitative nursing program 2-3 times per week.