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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the digital breast tomosynthesis for evaluation of the enrollees breast cancer examinationFindings:  All three reviewers found that Tomosynthesis is a technique that was developed as a problem solving adjunct to routine mammography. In this case, the patient has heterogeneously dense breasts. While one could make the argument that her mammogram has not changed since the last study, it is specifically those patients who have dense breasts that can benefit most from tomosynthesis. The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor. Final Result: All three reviewers determined that the services at issue were 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee requested Prometheus Anser IFX testing for evaluation of her Crohns disease.  Findings:  Three physician reviewers found that there is a lack of support for the services at issue in this clinical setting.  Inadequate response or loss of response can occur for many reasons.  However, the appropriate method for determining the cause of symptoms while on therapy is not clear.  The use of Prometheus Anser IFX testing to investigate response and direct subsequent management has not been proven to improve patient clinical outcomes or alter patient management.  The effectiveness of the services at issue in the management of Crohns disease compared with conventional courses of action remains unproven in controlled clinical trials.  The presence of antibodies alone does not necessarily result in loss of response, nor have threshold levels been established.  All told, the superior efficacy of Prometheus Anser IFX testing has not been established. 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: 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: Medical Necessity
Decision: Upheld

A 51-year-old female enrollee requested authorization and coverage for a referral to a registered dietician in a one-on-one environment for the treatment of a history of arthritis, pleurisy, synovitis, and obesity.  The health plan denied the enrollees request indicating that the requested services are not medically necessary.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: Medical Necessity
Decision: Overturned

A male enrollee requested mental health residential treatment for medical treatment of his behavioral health conditions.  Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the services at issue.  In this case, the patient had attempted treatment in the outpatient setting.  However, his alcohol and cocaine use dominated his daily routine, negatively impact his relationships and caused significant impairment across multiple domains of functionality.  His social and living environments were unable to support sober living.  Further, his drinking jeopardized his health and possibly the safety of others.  Finally, the patient had multiple co-occurring psychiatric conditions which compromised his prognosis.  He was described as minimizing his situation and lacking coping skills.  He continued to struggle with poor frustration tolerance and feelings of inadequacy.  Based upon the medical records, in the absence of residential programming, the patient was likely to have promptly relapsed.  All told, mental health residential treatment was medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for (1) consultation with an orthopedic surgeon who performs cervical and thoracic spinal surgery, and (2) spine surgery with an orthopedic surgeon who performs cervical and thoracic spinal surgery. Hemangioma of the vertebral body is a fairly common and often incidental finding on MRI/CT imaging of the spine. The majority of benign lesions in the thoracic and lumbar spine are asymptomatic. In the absence of objective neurologic deficit, surgery is not indicated for hemangioma or thoracic disc herniation. In this case, the medical records do not document any neurologic deficit. The patient has a chronic 17 mm hemangioma in the right side of the T9 vertebral body that has not increased in size since March 2019. MRI/CT imaging does not show cord compression, and there is no evidence of neurocompression of the thoracic disc herniation at T8-9. Based on the records, surgical consultation and spine surgery are not medically indicated. Therefore, (1) consultation with an orthopedic surgeon who performs cervical and thoracic spinal surgery, and (2) spine surgery with an orthopedic surgeon who performs cervical and thoracic spinal surgery are not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested services are 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 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Lenvima (10 mg daily dose) capsule therapy pack.There is a lack of support for the requested medication in this clinical setting. Lenvatinib has not been approved by the U.S. Food and Drug Administration (FDA) for the treatment of glioblastoma. The use of lenvatinib for glioblastoma is not supported by major drug compendia, the National Comprehensive Cancer Network guidelines, or medical literature. In a phase 2 trial by Reardon and colleagues, patients showed modest benefit, but only after treatment with bevacizumab. In this case, the patient has been diagnosed with glioblastoma. The patient has not yet received bevacizumab or other treatments. Therefore, Lenvima (10 mg daily dose) capsule therapy pack is not medically necessary for the treatment of the 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 internal medicine with sub-specialty certification in medical oncology 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 28-year-old female enrollee requested authorization and coverage of a referral to a high-risk obstetrician specialist. The Health Plan denied the request indicating that the requested referral is not medically necessary for treatment of the enrollees pregnancy.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plans denial on the basis that the requested referral is medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld

A 59-year-old female has requested Botox injections for treatment of her migraine headaches.   Findings:  Three physician reviewers found that the patient is being treated by an ear, nose and throat (ENT) provider for sinus symptoms and migraines. Per the submitted documentation, she has had nasal symptoms for several years. The provider notes indicate she has used sumatriptan, and that she is diagnosed with cluster/migraine headaches. The patient noted on the application that she has blinding headaches. She has previously undergone treatment with Botox 25-50 unit injections from her ENT provider. This patient has been diagnosed with migraines, but the records provided do not document headache characteristics, baseline frequency or other features that are consistent with a diagnosis of chronic migraines. Additionally, a comprehensive neurological evaluation was not included in the provided documentation. The patient has been treated with low dose Botox, however, the results and efficacy of this treatment are not documented in her medical records. Botox has been found to be beneficial for the prevention of chronic migraines, but has not been shown to be beneficial for the treatment of episodic migraines. The documentation provided does not support a diagnosis of chronic migraines. Also, the previous doses of Botox used to treat this patient have been found to be suboptimal in the treatment of migraines. Therefore, the requested treatment is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Tbo-filgrastim (Granix), 1 microgram injections (J1447). Findings:  The physician reviewer found that white blood count growth factors are supported to reduce a patients risk of neutropenic fever when the anticipated risk of neutropenic fever for a chemotherapy regimen is approximately 20% (Smith, et al.). This patients records document chemotherapy-induced neutropenia. Based on current data, prophylactic white blood count growth factors are indicated for this patient to help lower her anticipated neutropenic fever risk. Moreover, per the National Comprehensive Cancer Network (NCCN), to minimize possible emergency care needs during the COVID-19 pandemic, it is reasonable to provide prophylactic white blood count growth factors to patients with a 10% or greater anticipated neutropenic fever risk, such as this patient. All told, the requested Tbo-filgrastim (Granix), 1 microgram injections (J1447) are medically necessary for 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 internal medicine with subspecialty certifications in medical oncology and hematology 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 37-year-old female enrollee has requested Penlac for the treatment of onychomycosis.Findings:  The physician reviewer found that the only medically appropriate treatments for fungus nail infections are oral antifungals, fungoid solution and Penlac.
Appeal type: Experimental/Investigational
Decision: Upheld

A 60-year-old male enrollee has requested spinal fluid immunoassay for an evaluation of his condition. Findings:  Three physician reviewers found that it has not established that the patient has cognitive impairment. Measurement of cerebrospinal fluid tau and other proteins for diagnostic purposes is still investigational and not applicable to patients who are anxious about the possibility of having Alzheimers disease. The requested testing is not medically warranted for evaluation of this patient.
Appeal type: Medical Necessity
Decision: Overturned

An enrollee has requested authorization and coverage for the Femring vaginal ring. The patient has tried and failed multiple estrogen treatment options including the patch, gel, and creams. She has had allergic reactions and unscheduled vaginal bleeding from these treatments. She has tried alternatives, and has responded well to Femring. Given the patients clinical situation of her history of response to therapy and Femring's treatment of systemic symptoms, it is appropriate and medically necessary for the patient to continue treatment with Femring. 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 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for breast tomosynthesis screening mammogram for evaluation of the enrollees risk for breast cancer. Findings:  Three physician reviewers found that tomosynthesis was approved by the U.S. Food and Drug Administration (FDA) for clinical use in 2011. Despite the lack of long-term studies proving an increased survival rate when tomosynthesis has been used as part of screening mammography, the American College of Radiology (ACR) urged the technique be removed from the investigational category in 2014 due to the advantages this new tomographic technique brings to radiologists interpreting mammograms. This technique often allows radiologists to separate dense glandular elements from underlying masses and architectural distortion resulting in a decrease in callbacks and increased detection of small cancers. Thus, the addition of tomosynthesis to the usual two dimensional protocol was likely of greater benefit to this patient than had her exam been done with two dimensional imaging alone. Final Result: Three reviewers determined that the diagnostic procedure 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: 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

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for physical therapy services provided by Core Performance Physical Therapy. There is a lack of evidence-based practice guidelines in current medical literature on the duration, intensity, and delivery of rehabilitation modalities following total knee arthroplasty. Artz and colleagues reported that a systematic review showed that while interventions including physiotherapy and exercise showed short-term improvements in physical function in patients after total knee replacement, this conclusion was based on meta-analysis of a few small studies and no long-term benefits of physiotherapy exercise interventions were identified. Bandholm and colleagues found that studies of post-operative exercise-based interventions have not found superiority of one exercise regime over another. Davila Castrodad and colleagues noted that total knee arthroplasty is among the most common elective procedures performed worldwide and despite the many rehabilitation modalities available, the optimal rehabilitation strategy had yet to be determined. Wang and colleagues reported that following primary total knee arthroplasty comparable outcomes were demonstrated between patients in self-directed home exercise programs compared to those receiving outpatient physical therapy. In this case, the patient underwent extensive physical therapy. Her functional level and remaining deficits did not require ongoing skilled professional physical therapy and could have safely and effectively been met with an independent home exercise program. Therefore, physical therapy services provided by Core Performance Physical Therapy were not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the services at issue were 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 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for magnetic resonance imaging (MRI) of both breasts.Contrast enhanced breast magnetic resonance imaging (MRI) is more sensitive for the detection of breast cancer in the high-risk population, approximately 90% sensitive, than both mammography and ultrasound, approximately 38% individually. Screening breast MRI is recommended in women with a lifetime risk of greater than 20%, women with BRCA gene mutations and their untested first-degree relatives, as well as other high-risk populations. The American Cancer Society, American College of Radiology, and Society of Breast Imaging all recommend annual screening MRI in high-risk patients. In this case, the patients calculated lifetime risk of breast cancer is above 20% and she has dense breast tissue, therefore breast MRI is indicated as additional screening. Accordingly, the requested magnetic resonance imaging (MRI) of both breasts is medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested services are medically necessary to treat the patient's medical condition. Therefore, the Health Plans denial should be overturned.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: Overturned

The parent of a two-year-old male enrollee has for occupational therapy, speech therapy and ABA therapy for treatment of the enrollees autism. Findings:  The physician reviewer found that as the patient clearly meets the criteria of autism, a plan of therapy has to be based on the best medical practice and interventions.  Due to the nature of this neurological illness, with an unknown etiology, virtually all studies are relatively small and lack a gold standard of treatment.  Specialists recommend immediate, intensive intervention at the age of recognition. Per a recent review article in Pediatrics, occupational therapy (10 hours per week), speech therapy (twice per week) and ABA therapy (20 hours per week) are within the recommendations of this in-depth review.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Monovisc 88 mg/4 m bilateral knee injections. Findings:  The physician reviewer found that systematic reviews and randomized controlled trials indicate that although viscosupplementation may relieve knee pain in some patients with osteoarthritis, data has not established which patients will benefit. Guidelines from the American Academy of Orthopedic Surgeons (AAOS) indicate that the data on safety and efficacy of viscosupplementation remain inconclusive. As such, the AAOS does not currently recommend viscosupplementation as routine treatment for osteoarthritis of the knees. Viscosupplementation is reserved for patients with a history of lasting benefit from prior injections and in cases where the remaining options are limited. In this case, the patient has a history of inability to take non-steroidal anti-inflammatory drugs (NSAIDs). Previous treatment has included physical therapy as well as platelet rich plasma and corticosteroid injections. As such, the patients remaining treatment options are limited. For these reasons, the requested Monovisc 88 mg/4 m bilateral knee injections are medically necessary for 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 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.