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

The patient is a 58-year-old male with a long-standing history of migraine headaches and cardiac problems. He has been treated with a number of triptans, but continues to experience at least one headache per week. Most recently, the patient has been taking Zomig for acute relief. He has requested authorization and coverage for 18 Zomig tablets per month. The Health Plan has denied the patients request on the basis that the number of Zomig tablets requested is excessive and not medically indicated.Zomig is appropriate for patients who occasionally suffer an acute migraine headache. For patients who experience one migraine headache per week, a prophylactic medication such as Depakote or timolol is medically indicated. Given the frequency of the patients migraines, prophylactic treatment is medically appropriate and should be initiated. Furthermore, the number of Zomig tablets requested appears excessive and there is no clinical or scientific evidence demonstrating the requested prescription is medically indicated. Therefore, I have determined that the requested prescription is not medically necessary for the treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

A 41-year-old male enrollee requested authorization and coverage of a bone scan and a referral to an orthopedist. The Health Plan denied the request indicating that the requested services are not medically necessary for evaluation of the enrollees back pain.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer partially overturned the Health Plans denial on the basis that the requested referral to an orthopedist is medically necessary.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Verzenio, Herceptin, and Faslodex. The records provided for review document that this patients diagnoses include secondary malignant neoplasm of liver and intrahepatic bile duct, malignant neoplasm of central portion of right female breast, and malignant neoplasm of breast, unspecified site. The patients provider has recommended treatment with a regimen consisting of Verzenio, Herceptin, and Faslodex. The recently published results of the monarcHER trials showed a significant progression free survival in patients that were ER positive and HER2 positive treated with abemaciclib plus Herceptin with Faslodex versus Herceptin plus standard of care chemotherapy. This option does not use chemotherapy and is likely to be better tolerated then HER2-based chemotherapy, especially with the increased risk of infection. Given these findings, the requested Verzenio, Herceptin, and Faslodex are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Findings:  Two of the three physician reviewers found the requested Verzenio, Herceptin, and Faslodex are likely to be more beneficial for treatment of the patients medical 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 reviewer 1 is board certified in medical oncology with subspecialty certification in hematology and is actively practicing. Physician reviewer 2 is board certified in internal medicine with subspecialty certification in medical oncology and is actively practicing. Physician reviewer 3 is board certified in internal medicine with subspecialty certifications in medical oncology and hematology and is actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 44-year-old female enrollee has requested corrective spinal surgery/kyphoplasty for treatment of her L1 compression fracture.  Findings:  Three physician reviewers found that many of the available peer reviewed medical literature reviews studied the use of vertebroplasty and found that this treatment was not likely to be more beneficial than sham intervention. As for kyphoplasty, only one randomized controlled trial has been reported (Wardlaw, et al.).  This trial randomized 300 patients to kyphoplasty or usual medical care. The kyphoplasty group experienced significantly greater improvement in quality of life and decreased pain at all the measured time points from 1 month to 1 year. Compared with the medical care group, the reduction in pain in patients receiving kyphoplasty mirrored the results of the Vertos II trial, in which there was initially a considerably larger differential decrease in pain that tapered off over time. (Miller, et al.) Given the lack of double-blind evaluation, results of that trial should be interpreted with caution. Moreover, the similarity between this procedure and vertebroplasty makes it probable that the results reflect a placebo effect. Given the unproven benefit of kyphoplasty over placebo, kyphoplasty was not likely to be more beneficial for this patient than standard therapies.
Appeal type: Medical Necessity
Decision: Upheld

This patient had a colonoscopy in 1991 at which time inflammatory polyps were removed. Her colonoscopy in 1994 was normal. In 1999, another colonoscopy was normal. The patients father was diagnosed with colon cancer after age 60 and two aunts have also been diagnosed with colon cancer. The patient has requested authorization and coverage for a colonoscopy. The Health Plan has denied the patients request indicating a colonoscopy is not medically necessary at this time.The Health Plans denial should be upheld. For persons with a single first-degree relative diagnosed with colorectal cancer at age 60 or above there is an approximate two times greater risk of colon cancer than that observed in the general population. Furthermore, the risk for colon cancer at age 40 is the same as the risk in the general population at age 50. Thus, in this risk group the recommendations are the same as those for persons at average-risk (though screening should begin at age 40 rather than age 50). As such, a colonoscopy is not medically indicated for this patient at this time. Therefore, I have determined that the requested procedure is not medically necessary for evaluation of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

A female enrollee has requested authorization and coverage for vascularized lymph node transfer (VLNT) and lymphaticovenous anastomosis (LVA) procedures. The Health Plan has denied this request indicating that the requested procedures are not medically necessary for treatment of the enrollees lymphedema. A review of the records indicates that the enrollee has been diagnosed with lymphedema. The enrollee underwent excision of a left thigh liposarcoma with subsequent radiation therapy. Left thigh swelling was first reported, and a diagnosis of lymphedema was given. The records indicated a protein lipectomy was performed, and was noted as the first step in a comprehensive lymphedema treatment program. The provider noted the next step would be VLNT and LVA surgeries to repair and improve the lymphatic system. The submitted documentation supports the medical necessity of the procedures at issue. This patient has significant swelling of her left lower extremity related to post-surgery and post radiation for her left thigh liposarcoma. The initial SAPL (suction-assisted protein lipectomy) was performed as a prerequisite to the proposed VNLT (vascularized lymph node transfer) and LVA (lymphaticovenous anastomosis) procedures. This patient has failed conservative therapy, resulting in approval of the SAPL procedure, the proposed VNLT and LVA procedures should be considered medically necessary in the treatment of this patient's severe left lower extremity lymphedema. The current medical evidence supports the medical necessity of the proposed procedures in this clinical setting. Therefore, the requested vascularized lymph node transfer (VLNT) and lymphaticovenous anastomosis (LVA) procedures are medically necessary for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested the LINX anti-reflux procedure for treatment of her medical condition.  Findings:  Two physician reviewers found that the LINX device has been approved for patients with diagnosed gastroesophageal reflux disease as defined by abnormal pH testing, and who continue to have chronic gastroesophageal reflux disease symptoms despite maximal medical therapy for the treatment of reflux.  This patient has documented gastroesophageal reflux disease based on endoscopic and radiographic data.  However, it is documented she has benefited to a significant degree from acid suppression treatment, and as such cannot be considered medically refractory to acid blocker drugs.  Further, implantation of LINX in this clinical setting must be approached with caution given her documented complaints of dysphagia and the manometric finding of ineffective esophageal motility. In sum, the requested LINX anti-reflux procedure is not likely to be of greater benefit than other treatment options. Final Result: Two reviewers determined that the requested services are not likely to be more beneficial for treatment 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 gastroenterology 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 reimbursement and prospective authorization and coverage for 36 hours per week of direct applied behavioral analysis (ABA) therapy, 15 hours per month of supervision and two hours per month of parent training for treatment of the autism spectrum disorder. Findings:  The physician reviewer found that continued ABA therapy has been authorized by the Health Plan, but at a reduced rate. The correlation between treatment outcomes and treatment intensity is well documented in the peer-reviewed literature. One study found a strong relationship between treatment intensity and mastery of learning objectives. The Behavior Analyst Certification Board states that typical comprehensive ABA programs range from 30 to 40 hours of treatment per week. In this case, the patient demonstrates high levels of stereotypic hilarity, inappropriate coping, and vocal stereotypy (level 2) along with delays in adaptive skillsets as measured across multiple domains. The patient also requires a high level of support to complete activities of daily living. While the patient has met his behavior goals, he continues to demonstrate stereotypical hilarity up to 3.5 times per hour, and inappropriate coping up to 100% of the times measured. 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 pediatrics with sub-specialty certification in developmental-behavioral pediatrics 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 an evaluative test of amniotic fluid protein for evaluation of her pregnancy.  Three physician reviewers found that in this patients case, the services at issue were not likely to have been of greater benefit than other methods of evaluation.  The diagnosis of ruptured membranes can generally be made on the basis of clinical examination and nitrazine and fern testing.  There have been false positive results from AmniSure.  There is nothing in the record to suggest that there was clinical confusion as to the presence of ruptured membranes by physical examination, nitrazine testing, or ferning.  It does not appear that these standard evaluations were performed.  The routine use of AmniSure to diagnose ruptured membranes is not recommended.  All told, the evaluative test of amniotic fluid protein was not likely to have been more effective than other options for evaluating this patient. 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 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for acupuncture.  Findings:  The physician reviewer found that there is sufficient support for the requested services in this clinical setting.  This patient has had acupuncture in the past which was beneficial in reducing his symptoms.  Therefore, since he was symptomatic, the patients provider recommended additional acupuncture.  The current medical evidence supports additional acupuncture treatment in this patients case.  Trinh and colleagues noted there is strong evidence suggesting that acupuncture is effective in the short-term relief of lateral epicondyle pain.  According to a study, studies suggest that acupuncture is more effective than sham acupuncture.  Final Result: The reviewers 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 physician reviewer is board certified in oriental 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

The patient is a nine-year-old male who has been diagnosed with autism. He has received speech therapy since 1998. Documented speech testing results reveal the patient continues to be approximately two years behind in language skills with receptive language and expressive language at less than 1 percentile in most categories. Clinical evaluation of language (CELF) testing shows the patients overall language in most categories is less than the 25th percentile. At issue is whether continued speech therapy is medically necessary for treatment of the patients medical condition.Current medical literature fails to establish the efficacy of speech therapy in the treatment of autism. Furthermore, because the loss of speech and other behavioral issues are related to communication and social issues associated with autism there is no medical indication for speech therapy for patients such as this patient. In cases such as this, speech therapy can typically be appropriately provided through means other than individual therapy. Therefore, I have determined that the requested therapy is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of a 10-year-old female enrollee has requested authorization and coverage for MRI cervical spine without contrast, MRI thoracic spine without contrast, and MRI lumbar spine without contrast. The Health Plan has denied this request indicating that the requested service is not medically necessary for treatment of the enrollees scoliosis. A review of the records indicates that the enrollee is diagnosed with adolescent idiopathic scoliosis. Visit notes, indicated the enrollee had no associated back pain, and an x-ray is reported to have shown scoliosis of the thoracic lumbar spine, which had progressed from prior x-rays. The provider recommended magnetic resonance imaging (MRI) to rule out neurologic cause for the curvature. The American College of Radiation states magnetic resonance imaging (MRI) of the spine is a powerful tool for the evaluation, assessment of severity, and follow-up of diseases of the spine. Spine MRI should be performed only for a valid medical reason. Congenital abnormalities of the spine and spinal cord can be detected in screening tests of scoliosis, in patients with clinical suspicion or incidentally. MRI of the entire spine can be used as a screening test for anomalies. The National Imaging Associates (NIA) guidelines state any combination of (Cervical/Thoracic/Lumbar MRIs) are supported for scoliosis survey in infant/child. In this case, the patient was diagnosed with adolescent idiopathic scoliosis. The pediatrician noticed this curvature in March 2018. The doctor is trying to rule out neurologic cause or a congenital anomaly such as tethered cord, which may result in increased scoliosis. `Congenital abnormalities of the spine and spinal cord can be detected in screening tests of scoliosis, in patients with clinical suspicion or incidentally. MRI of the entire spine can be used as a screening test for anomalies. Furthermore, the NIA guidelines state any combination of (Cervical/Thoracic/Lumbar MRIs) are supported for scoliosis survey in infant/child. As such, the requested MRI of the lumbar, thoracic, and cervical, without contrast would be considered medically necessary.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 physical medicine & rehabilitation and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Santyl ointment. Findings:  The physician reviewer found that this patient has a history of a diabetic foot ulcer for 1.5 weeks. He was evaluated and reported no improvement with home health treatment. On physical examination, he was found to have an ulcer with diabetes. He also has a history of neuropathy. Santyl ointment is indicated for diabetic patients with foot ulcers. In addition, Santyl ointment has been shown to be effective in chronic wounds. Given the lack of improvement with home health services, the requested Santyl ointment is medically necessary treatment of this patients medical condition. 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 internal medicine with sub-specialty certification in infectious 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 34-year-old female has requested coverage for lumbar spinal fusion at L5-S1 for treatment of her low back pain.  Findings:  The physician reviewer found that there is a lack of high quality studies examining the role of surgical fusion as a treatment for lumbar disc herniation and radiculopathy (Resnick, et al.). However, Resnick and colleagues noted the following with regard to fusion: lumbar spinal fusion is not recommended as routine treatment following primary disc excision in patients with a herniated lumbar disc causing radiculopathy; lumbar spinal fusion is recommended as a potential surgical adjunct in patients with a herniated disc in whom there is evidence of preoperative lumbar spinal deformity or instability; lumbar spinal fusion is recommended as a potential surgical adjunct in patients with significant chronic axial low back pain associated with radiculopathy due to a herniated lumbar disc; re-operative discectomy is recommended as a treatment option in patients with a recurrent lumbar disc herniation; re-operative discectomy combined with fusion is recommended as a treatment option in patients with a recurrent disc herniation associated with lumbar instability, deformity or chronic axial low-back pain. In this particular case, there is a lack of evidence of spinal deformity. Further, instability or disc re-herniation is not documented. Moreover, there is no evidence of significant radiculopathy. As such, the patient does not fit any of the above criteria for fusion. Review of the scientific literature demonstrates that fusion for the treatment of non-radicular back pain is no more effective than intensive rehabilitation (Chou, et al.). Given the paucity of studies demonstrating the safety and efficacy of surgical fusion in this setting, the requested procedure is not medically necessary for treatment of the patients low back pain.