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

Nature of Statutory Criteria/Case Summary: An enrollee requested authorization and coverage for Stelara every four weeks. In this clinical setting, current medical literature supports a dose escalation of Stelara to 90 mg every four weeks. In a large randomized controlled trial, Sandborn and colleagues demonstrated the safety and efficacy of ustekinumab (brand name Stelara) for induction and maintenance of remission in patients with moderate to severe Crohns disease that was resistant to anti-tumor necrosis factor (TNF) therapy. In a study of 38 patients with anti-TNF-resistant Crohns disease, Kopylov and colleagues noted a 73% initial clinical response to ustekinumab, and 80% of responders maintained remission for one year. Tuskey and Behm note that the mechanism of ustekinumab is entirely different than that of anti-TNF medications. Battat and colleagues noted the efficacy of ustekinumab therapy, at a dosing of 90 mg every four or eight weeks during maintenance. In this case, the patient has symptoms and colonoscopy findings consistent with active Crohns disease while on Stelara every eight weeks. They failed Remicade and Humira.  In this case, the requested medication regimen is likely to be more beneficial than continued dosage of Stelara every eight weeks or transitioning to another medication, which may result in worsening disease control with complications such as fistula, stricture, bowel obstruction, flare, or the need for hospitalization or surgery. Therefore, Stelara every four weeks is likely to be more beneficial for treatment of the patients condition than any available standard therapy.Final Result: The reviewers determined that the requested medication regimen is 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 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: Experimental/Investigational
Decision: Overturned

A 62-year-old male enrollee has requested SPECT (SPECT/CT fusion imaging scan, parathyroid planar imaging) scan for evaluation of his medical condition. Findings:  Three physician reviewers found that the services at issue were likely to have been of greater benefit than other modalities for evaluating this patient.  The SPECT scan is a well-established method of differentiating parathyroid adenoma from parathyroid hyperplasia.  Additionally, the SPECT scan can provide information regarding the size and site of the adenoma.  There is sufficient support for the services at issue in this clinical setting.  Therefore, SPECT (SPECT/CT fusion imaging scan, parathyroid planar imaging) scan was likely to have been more efficacious than other methods of evaluation.
Appeal type: Experimental/Investigational
Decision: Upheld

A 30-year-old male enrollee requested sacroiliac (SI) joint fusion for medical treatment of his back pain.  Findings:  Three physician reviewers found that the requested services are not likely to be more effective for this patient than other available options. According to the U.S. National Library of Medicine, conservative management for sacroiliac joint pain includes rest, ice therapy, heat therapy, massage, and oral pain medication. An injection may be administered to help with pain and inflammation.  Based on the clinical information received and peer-reviewed literature, the sacroiliac joint fusion is not indicated in this clinical setting. As such, the requested services are not likely to be more beneficial for treatment of this patients medical condition than the available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld

This patient is a 36-year-old female with sudden hearing loss. Audiological studies confirmed severe sensorineural hearing loss (SNHL) on the right. The patient was seen by an otolaryngologist and a seven-day course of prednisone and acyclovir was prescribed. Within the same timeframe, the patient consulted with an acupuncturist and received four acupuncture treatments. The patients hearing loss subsequently resolved, but the tinnitus has persisted. The patients request for reimbursement and prospective authorization for acupuncture treatment was denied by the Health Plan citing a lack of medically necessity.The studies reviewed had very split results and generally the Chinese studies reached the conclusion that acupuncture worked for SNHL and tinnitus. Studies in the context of traditional western medicine  came to the conclusion that this treatment is not effective. None of the studies were very powerful and conclusions were based on small sample sizes. These studies were not well-controlled or randomized would not withstand the scrutiny of peer review. As such, there is no compelling scientific evidence at this time that acupuncture, alone, can effectively reverse the effects of sudden SNHL. It may have had value as an adjuvant therapy, but the reversal of the patients sudden hearing loss was most likely due to steroid therapy. Additionally, there is no evidence to support the efficacy of on-going acupuncture therapy as treatment for residual tinnitus. Therefore, I have determined the therapy at issue was/is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

A 44-year-old male enrollee has requested Levaquin for the treatment of his rhinosinusitis. Findings:  The physician reviewer found that the submitted clinical evidence demonstrates that the patient was treated with a variety of antibiotics for several months for sinusitis that had been present. His condition did not appear to improve significantly and sinus surgery was performed. The organism recovered at that time (Stenotrophomonas maltophilia) is a recognized cause of respiratory disease and treatment of this organism was very appropriate. While antibiotics are not first-line therapy for sinusitis, in this case, the positive culture does indicate treatment was needed. The organism was reported as being sensitive to Levaquin and trimethoprim-sulfamethoxazole; thus, the use of Levaquin was a reasonable choice to treat the apparent infection. Note that no other quinolone was tested by the hospital laboratory against the Stenotrophomonas recovered at surgery. For these reasons, the Levaquin prescriptions prescribed after the organism was identified were appropriate and therefore medically necessary. However, the Levaquin ordered the following month was used for nasal irrigation which is not an appropriate indication for the antibiotic and was not medically necessary. Furthermore, the Levaquin prescription prescribed before the surgery does not contain cultural documentation and this drug was not clearly indicated on that basis and should be denied for reimbursement on grounds that it too was not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

A 46-year-old female enrollee has requested outpatient psychotherapy, two sessions per week for treatment of her post-traumatic stress disorder and generalized anxiety disorder. Findings:  The physician reviewer found that psychotherapeutically, current practice is focused on aggressive treatment of anxiety, particularly in the acute phase of the illness, followed by less frequent services in the maintenance phase to foster patient autonomy and recovery.  Thus, it is not uncommon for transient weekly, or even twice- and thrice-weekly, sessions to be medically necessary in the treatment of anxiety disorders.  However, evidence-based therapies for both post-traumatic stress disorder, such as prolonged exposure and cognitive processing therapy, and generalized anxiety disorder, which include cognitive behavioral therapy, psychodynamic therapy, mindfulness and interpersonal therapy, necessitate reevaluation of effectiveness and goal progression during protracted treatment courses.  The documentation provided in this case does not include any input from the treating provider to justify ongoing treatment at the requested frequency.  Most notably absent is a comprehensive treatment plan.  An individualized and up-to-date treatment plan is a crucial document that develops and organizes interventions aimed at maximizing the patients level of functioning as well as helping the patient to set specific goals appropriate to his or her functional impairments and symptom severity.  In the absence of medical documentation, the medical necessity of the services at issue has not been established.  Therefore, outpatient psychotherapy, two sessions per week, from the date specified forward were not and are not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

A female enrollee requested Simponi 50 mg subcutaneous (SQ) monthly for medical treatment of her rheumatoid arthritis. Findings:  The physician reviewer found that Simponi is a well-established, U.S. Food and Drug Administration (FDA) approved medication for the treatment of rheumatoid arthritis. In addition, the authors found that at 160 weeks, 57-67% of patients who continued with Simponi after discontinuing a previous TNF inhibitor treatment experienced sustained improvement in signs, symptoms, and physical function. Since this patient has failed Humira, treatment with the requested Simponi 50 mg SQ monthly is medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested for intravenous immunoglobulin, Gammagard (IVIG) treatment for treatment of the enrollee who has been diagnosed with chronic inflammatory demyelinating polyradiculoneuropathy. Findings: The physician reviewer found that there is sufficient support for the requested services in this patients case.  Intravenous immunoglobulin remains the appropriate treatment for this patients chronic inflammatory demyelinating polyradiculoneuropathy.  The patient meets clinical criteria for this diagnosis, and intravenous immunoglobulin remains a first-line medication in this clinical setting.  The current medical evidence supports the requested services for the treatment of this patient.  All told, intravenous immunoglobulin, Gammagard (IVIG) treatment, at the provider requested frequency is medically indicated for the treatment of this patient.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 neurology 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested advanced lipoprotein testing for treatment of her medical condition. Findings: Three physician reviewers found that in this clinical setting, primary prevention guidelines currently do not recommend routine performance of specialized tests in the context of assessing coronary risk including lipoprotein-associated phospholipase A2 (Lp-PLA2), lipoprotein(a), C-reactive protein (CRP), high sensitivity CRP, insulin, fibrinogen, genetic testing and homocysteine.  Treatment change or addition based on the results of screening with these specialized tests has not been shown to improve cardiac outcome incremental to that achievable by treatment based on standard risk factor profiling and basic lipid analysis.  All told, the advanced lipoprotein testing was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.  Final Result: Three reviewers determined that the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.   Credentials/Qualifications: All three reviewers are board certified in internal medicine with sub-specialty certification in cardiovascular disease 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

Nature of Statutory Criteria/Case Summary:   The parent of an enrollee has requested growth hormone (GH) therapy with Genotropin for treatment of the enrollees short stature. The physician reviewer found that according to the Lawson Wilkins Pediatric Endocrinology Society guidelines, a trial of GH therapy should be approved for children with otherwise unexplained short stature who pass GH stimulation tests but who meet most of the following criteria: (1) height more than 2.25 standard deviations below the mean for age or more than two standard deviations below the mid-parental height percentile; (2) growth velocity less than 25th percentile for bone age; (3) bone age more than two standard deviations below the mean for age; (4) low serum IGF-1 and/or IGFBP-3; and/or (5) other clinical features suggestive of GH deficiency. This patient meets at least four of these criteria. Provocative GH tests have poor sensitivity and specificity for the diagnosis of GH deficiency, so the normal response to testing is not reassuring in the setting of auxological evidence of growth failure, low growth factors, and a markedly delayed skeletal maturation. All told, the medical records support the requested GH therapy with Genotropin as medically necessary for treatment of this patients short stature.  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 pediatric endocrinology 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

This case concerns the treatment of a 13-year-old male with diagnoses of attention deficit hyperactivity disorder (ADHD) and oppositional defiant disorder (ODD). The patient has been treated at the partial hospitalization program (PHP) level of care since January 2006. The Health Plan covered the care until February 2006. The submitted records reveal that the patient was adopted shortly after birth.  He developed symptoms consistent with ADHD and ODD, but did not respond to the traditional medications and continued to destroy property at home.  He also failed an outpatient course of treatment.  The Health Plan authorized a PHP level of care with the goals of stabilizing the patient pharmacologically, offering the parents guidance and providing assistance with management of his behaviors at home and at school.   The patients provider indicated in February 2006 that the patient has had mild response to treatment with Focalin. In addition, it was noted he continues to exhibit ongoing severe dysfunction at home and in our highly structured milieu.  The provider states the patient is unable to function in a community school and continues to have conflicts with his mother and father at home.  At that time it was recommended that the patient continue to receive PHP services. The Health Plan denied coverage for the PHP beyond February 2006 on the basis that the services were no longer medically necessary.A review of the chart reveals that the patient has made mild improvement with interaction with peers and in school.  There has been continuing problems with the child-parent relationship.  Based upon his behavior in the PHP the patient is likely to need a special education program or a private school. His response to medication has been atypical for a child with ADHD and ODD.  The current approach to medications appears to be helpful, but the optimal approach to the stabilization of this patient will be a combination of a structured school, pharmacological intervention, parental training in the use of a behavioral modification program and individual therapy for the patient.  The PHP was able to utilize pharmacological intervention and to start to engage the parents. As of February 2006, the patient was sufficiently stable to receive treatment on an outpatient basis. There is no evidence in the submitted records that continued PHP was required beyond February 2006. Accordingly, I have determined the requested services are not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

The parents of a 16-year-old male enrollee have requested a CPM (continuous passive motion machine) and a cooling device (via an electronically-controlled circulating pump) for the treatment of the enrollees condition. Findings:  The physician reviewer found that the central issue to consider in this case is whether the CPM and cooling devices were medically necessary in the patients rehabilitation after knee surgery. The cooling device is considered a convenience item and was not truly needed. The patient could have used standard cold or ice packs in order to reduce pain and swelling.  In addition, the CPM is not a necessary device to restore range of motion after this type of surgery.   Traditional post-operative physical therapy or home exercise programs given by the physician would have provided the same benefits as the CPM machine such as increasing nutrition and joint range of motion, enhancing collage reformation, and reducing the possibility of adhesion formation.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a 16-year-old female enrollee has requested adolescent psychiatric residential treatment services for the treatment of the enrollees mood disorder, not otherwise specified, and polysubstance dependence. Findings:  The physician reviewer found that the submitted clinical evidence demonstrates that the patient has had outpatient treatment, which she left prior to completing. She has also intermittently taken Wellbutrin. There is no evidence the patient had any other outpatient treatment, partial hospital treatment or intensive outpatient treatment prior to her admission to the residential treatment center. Based upon the psychiatric evaluation, medical management notes, monthly resident review and milieu progress noted, the patient has had no psychotic symptoms during her inpatient admission and there is no evidence she is at risk of harm to self or others. As of a recent progress note, the patient had not been prescribed any psychotropic medication. All told, the medical necessity of adolescent psychiatric residential treatment services has not been established. This patient could have been effectively and safely treated at a lower level of care
Appeal type: Experimental/Investigational
Decision: Upheld

A 35-year-old female enrollee requested authorization and coverage of biofeedback for treatment of urinary incontinence.  The health plan denied the enrollees request indicating that the requested treatment is considered experimental.Three physician reviewers performed an experimental/investigational Independent Medical Review.  Each of the three physician reviewers concluded that biofeedback is not likely to be more beneficial for treatment of the enrollees urinary incontinence than any available standard therapy.  Because all three physician reviewers concluded that the requested treatment is not likely to be more beneficial for treatment of the enrollees medical condition than any available standard therapy, the review organization upheld the health plans denial.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 52-year-old woman with bilateral breast implants who was referred to a plastic surgeon for evaluation of chest pain. The patient has had chest pain intermittently beneath the right breast since a fall from a horse approximately four years ago. The evaluation by the plastic surgeon revealed bilateral Baker I soft implants that appeared to have been placed through axillary incisions. The patient has requested authorization and coverage for removal of the breast implants. The Health Plan has denied the request on the basis that the requested procedure is not medically necessary.Review of the submitted records shows that the patients previous mammograms and chest x-rays did not demonstrate etiology for the patients reported pain. Thus, there is no evidence that removal of the implants will provide the patient with relief. Furthermore, there is no evidence that the requested procedure is being sought to improve function. Based upon the information provided, it appears removal of the patients breast implants has been requested for personal reasons and is not medically indicated. Therefore, I have determined that the requested procedure is not medically necessary for the treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

A 60-year-old female enrollee has requested a PET scan and/or a lung biopsy for an evaluation of her lung nodules. Findings:  The physician reviewer found that the submitted clinical evidence demonstrates that this patient had a CT scan of the chest. The only pulmonary indications for a PET scan are a solitary pulmonary mass for evaluation of lung cancer or restaging of a patient with known cancer after treatment. This patient has a 5 mm nodule that is unchanged and multiple bilateral pulmonary nodules with no documentation of change. There are no indications present that demonstrate the medical necessity of a PET scan or a lung biopsy.