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

Nature of Statutory Criteria/Case Summary: The enrollee has requested reimbursement for the heart scan coronary computed tomography angiography (CCTA) provided. Findings:  The physician reviewer found that based on the records provided, the patient presents with some coronary risk but no documented coronary disease. In this circumstance guidelines for the management of cardiac risk and dyslipidemia have been established, are periodically updated by expert committees and are endorsed by several national organizations. These guidelines currently do not recommend routine performance of specialized tests in the context of assessing coronary risk including coronary CT scanning . Treatment change or addition based on the results of screening with CCTA 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 CCTA provided was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: All three reviewers determined that the diagnostic procedure at issue was 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: Physician reviewer 1, 2 & 3 are board certified in internal medicine with sub-specialty certification in cardiovascular disease 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 parents of a 15-year-old female enrollee requested authorization and coverage of myofascial release therapy for treatment of the enrollees medical condition. The Health Plan denied the request indicating that the requested therapy is not medically necessary for treatment of the enrollees back pain.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plans denial on the basis that the six treatments of requested therapy are medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

An enrollee has requested authorization and coverage for H.P. Acthar Gel.The medical literature does not support that the requested medication is medically necessary. At this time, there are no good, randomized, double blinded, placebo-controlled studies in support of H.P. Acthar for rheumatoid arthritis, but rather small reports. H.P. Acthar is still being studied in clinical investigations as well as for other indications such as rheumatoid arthritis and sarcoidosis. Acthar is not proven to be superior to oral steroids or immunosuppressive medications such as Imuran and may actually result in increased ocular issues with progressive cataracts and glaucoma. Acthar Gel is also not superior to combination therapy for rheumatoid or other anti-tnf agents or biological medications. Acthar Gel remains the subject of many clinical trials at this time. In this case, H.P. Acthar Gel is not intended to be a form of chronic therapy for this patient, who has a history of non-response to various oral steroids as well as DMARDS and Humira. H.P. Acthar has a corticotropin effect and with that, the same potential side effect profile as steroids with respect to osteoporosis, glaucoma, cataracts, weight gain, increased blood pressure and glucose intolerance. Under these circumstances, H.P. Acthar Gel is not medically necessary for 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 subspecialty certification in rheumatology, 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 acupuncture for treatment of her back pain.  Findings:  The physician reviewer found that review of the submitted documentation and relevant literature demonstrates the medical necessity of the requested services. According to the documentation submitted for review, the patient presents with chronic lower back pain. The peer review literature has several quality studies supporting treatment with acupuncture in this clinical setting. A medical study performed a randomized control trial to assess acupunctures effectiveness for treating low back pain. The authors concluded that Acupuncture effectively relieves chronic low back pain. In addition, the medical literature indicated that the effectiveness of acupuncture is almost twice that of conventional therapy. Given the clinical documentation submitted for review and the support in the peer-reviewed literature, the request for acupuncture is supported as medically necessary for treatment of the patients medical condition.  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 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 parents of an 11-year-old female enrollee have requested growth hormone therapy (Nutropin AQ 10mg) for the treatment of the enrollees growth failure leading to short stature. Findings:  The physician reviewer found that the patient appears to have constitutionally delayed puberty and should achieve an adult height beyond the lower limit set by the FDA in their 2003 ruling on the use of growth hormone therapy for idiopathic short stature. Thus, in this patients case, growth hormone therapy is not medically indicated or appropriate.
Appeal type: Experimental/Investigational
Decision: Upheld

A 34-year-old female enrollee has requested authorization and coverage for decompression therapy for treatment of the enrollees back pain. Findings:  Three physician reviewers found that the patient has chronic low back pain.  Her diagnoses include lumbar degenerative disc disease, failed lumbar laminectomy syndrome, and lumbar facet arthrosis.  The patients symptoms have persisted despite multiple interventions, including physical therapy, epidural injections, pharmacotherapy, and right hemilaminectomy.  She has requested coverage for decompression therapy.  Mechanized spinal distraction therapy is not of proven benefit for the treatment of any condition, including back pain.  While claims have been made that mechanical traction using these types of devices can relieve spinal pain by decompressing discs, improving the flow of nutrients into the disc and rehydrating dried-out discs, these claims have not been substantiated by data from published peer-reviewed studies.  There is a lack of randomized, controlled trials in the literature supporting the requested services.  The trial by Sherry and colleagues had significant methodological problems, including insufficient randomization procedures, suboptimal utilization of TENS in the control arm, and a lack of blinding by evaluators.  In this patients case, no significant improvement in her symptoms, clinical course, or outcomes is expected with the requested services.  There is a paucity of high-grade published studies supporting the clinical effectiveness of this intervention.  All told, the requested decompression therapy is not likely to be more efficacious than other treatment modalities in this patients case.
Appeal type: Experimental/Investigational
Decision: Overturned

A 58-year-old male enrollee has requested for a continuous glucose monitoring system and associated insulin pump for treatment of his diabetes. Findings:  Two physician reviewers found that there is evidence that this device improves net health outcomes in someone such as this patient who is having severe hypoglycemic reactions and needs to avoid low blood sugars. The literature also supports CGMs as improving HgA1c levels over time.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for an additional five hours per week (for a total of 25 hours per week) of Applied Behavior Analysis (ABA). The Council of Autism Service Providers guidelines on ABA treatment of autism spectrum disorder note that focused ABA plans are appropriate for individuals who (a) need treatment only for a limited number of key functional skills or (b) have such acute problem behavior that its treatment should be the priority. In this case, the records note 15 goals and an acute presentation of challenging behavior including nearly six tantrums daily. The guidelines further note that treatment dosage, or intensity of services, will vary among patients and should reflect the goals of treatment, specific patient needs, and response to treatment. In this case, the patient is making progress at the requested intensity. This intensity should continue until the transition plan criteria is met and a reduction to fewer hours is warranted. Papatola and Lustig report that ABA services should be consistent in type, frequency, and duration of treatment with scientifically based guidelines as determined by medical research, and that they should be rendered in the least intensive setting that is appropriate for the delivery of health care. Given that the treatment plan includes all essential elements and meets the core components of ABA guidelines, the requested service is medically indicated. In this patients case, the requested services are in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, the requested services are clinically appropriate in terms of type, frequency, extent, site, and duration. The requested services are not primarily for the economic benefit of the health care service plan and subscribers or for the convenience of the patient, treating physician, or other health care provider. Therefore, an additional five hours per week (for a total of 25 hours per week) of applied behavior analysis (ABA) are medically necessary 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 licensed B.C.B.A, board certified in psychology, 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 62-year-old woman enrollee requested authorization and coverage of a DEXA scan for evaluation of bone mineral density.  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 upheld the health plans denial on the basis that the requested services are not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for one percent testosterone cream compound. Studies have concluded that evidence is lacking to support superiority claims of compounded bioidentical hormones over conventional menopausal hormone therapy. Studies also concluded that customized compounded hormones pose additional risks, as these preparations have variable purity and potency and lack efficacy and safety data. Because of inability and bioactivity, both under dosage and over dosage are possible with compounded bioidentical hormones. Studies haave noted that compounded drugs are not regulated by the U.S. Food and Drug Administration (FDA); they have the same risks as FDA-approved hormone therapies, and they also may have additional risks because of the way they are made. The Committee observed that over a six-month period, the FDA performed repeat analytic testing of 29 internet-ordered samples, including estradiol and progesterone from 12 compounding pharmacies. Although none of the preparations failed identity testing, 10 of the 29 preparations (34 percent) failed one or more standard quality tests performed, including potency testing. In contrast, the analytical testing failure rate for drug therapies approved by the FDA is less than two percent.Although testosterone can be helpful in the prevention of osteoporosis, it is not a first-line therapy, as the unknown risks do not outweigh the benefits. There are many other therapies that can be utilized for osteoporosis prevention, such as weight-bearing and core exercises, avoiding certain medications and foods, avoiding excessive drinking and smoking, a healthy amount of calcium in the diet, vitamin D supplementation, and various FDA approved therapies such as bisphosphonates, Evista, and Prolia.In this case, the patients menopause complaints are centered around her desire to use testosterone hormone replacement for improvement of energy and libido. It is also claimed that her bone density improvement (osteoporosis and hip fracture prevention) is directly related to testosterone use. Despite the success the patient may be experiencing with menopausal symptoms, testosterone hormone replacement is not recommended, especially as first-line therapy. Based upon the submitted clinical notes and current peer-reviewed literature, the requested 1% testosterone cream compound is not medically necessary for 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 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: Upheld

The parent of a 21-year-old female enrollee has requested for services for depressive disorder, bipolar disorder and borderline personality disorder.  Findings:  The physician reviewer found that there is no evidence to support the need of the services at issue.
Appeal type: Experimental/Investigational
Decision: Upheld

A 28-year-old female has requested transcranial magnetic stimulation (TMS) therapy for treatment of her depression.  Findings:  Two physician reviewers found that the patient has a thirteen-year history of a depressive disorder and treatments. She does not have any history of co-morbid chemical dependency and her medical status is reflected as stable. The patient is reported as having had two suicide attempts, the most recent of which was within the past year. Her diagnosis is listed as major depressive disorder, chronic recurrent, severe without psychotic features. The patient has tried and failed treatment with outpatient therapy and medications, including: Lexapro, Prozac, Pristiq, Effexor and Abilify. She has also undergone approximately twenty treatments with cognitive behavioral therapy (CBT). The patient has participated in a partial hospital program (PHP). The patient has requested authorization for transcranial magnetic stimulation (TMS) therapy, which was denied by the Health Plan. Given the records provided for review, the requested TMS therapy is not likely to be more beneficial for treatment of this patients medical condition than any available standard therapy including medication augmentation strategies with psychotherapy and consideration of ECT. The peer-reviewed medical literature suggests that ECT remains the most effective form of therapy in this setting. As noted by Slotema and colleagues, ECT has been shown to provide superior results in the treatment of patients with depression. While concern for potential side effects associated with ECT does exist, and patients must be appropriately screened, there is no indication that this patient has any co-morbid medical conditions that would pose a potential risk in the context of ECT administration. Additionally, the safety and efficacy of TMS therapy has not been established in special patient populations, including patients who have suicide plan or have recently attempted suicide. In this case, the patients history reflects two suicide attempts, with the most recent being eleven months ago. Accordingly, it has not been established that the requested TMS therapy is likely to be more beneficial for this patient than standard treatment modalities.
Appeal type: Medical Necessity
Decision: Overturned

A 22-year-old male enrollee has requested acute psychiatric care for treatment of his major depressive disorder and post-traumatic stress disorder.  Findings:  The physician reviewer found that based on review of the available records, this patient had impaired functioning socially and occupationally with signs and symptoms noted throughout his admission. Despite intensive outpatient therapy, his symptoms had not improved. Further, the patients depressed mood, hopelessness, insomnia, lack of energy, anhedonia, and isolativeness persisted throughout the admission indicating the need for ongoing treatment. A discharge global assessment of functioning (GAF) score of 35 also supports the indication for acute psychiatric level of care treatment. Consistent with these findings, the acute inpatient hospitalization during the said timeframe was appropriate to treat the patients condition, consistent with standards of good medical practice, and could not have been provided safely in a less restrictive setting. As such, the services at issue were medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 20-month-old female enrollee has requested physical therapy for treatment of the enrollees functional mobility deficit.  Findings:  The physician reviewer found that physical therapy is medically necessary for treatment of the patients medical condition. The physical therapy requested would help restore physical functions for the patients developmental delays. The article by Scherzer and colleagues noted that developmental delay can be improved upon with help from the family, but also with assistance from trained professionals. According to the authors, The incorporation of early evaluation and intervention programs into routine pediatric care is likely to have the most impact on the quality of life of these children. We therefore call for leadership from practitioners, governments, and international organizations to prioritize regular childhood developmental surveillance for possible delays and disabilities, and to pursue early referral for intervention. As such, based on the medical records submitted for review and the medical literature cited above physical therapy is medically necessary as the therapy would help restore physical functions for this patient. Therefore, the medical necessity for the requested therapy has been established in this clinical setting.
Appeal type: Experimental/Investigational
Decision: Upheld

A 70-year-old male enrollee has requested computer-guided assistance during total knee replacement surgery for treatment of his medical condition. Findings:  Two physician reviewers found that computer-assisted navigation was designed in hopes of increasing the precision of total hip and total knee replacement surgery. However, this technology has not been widely adopted. Some studies have shown that there is no significant difference in post-operative component position and limb alignment between computer-assisted navigation and conventional surgical techniques. Other studies have demonstrated that there was a tendency towards improved component position and limb alignment in total knee replacement utilizing computer-assisted navigation. However, these studies (with short to mid-term follow-up) have not shown that the decrease in alignment variability resulted in an improvement in clinical outcomes. It is not possible to determine from these studies whether the relatively small degree of improvement in alignment translates into increased implant longevity and/or improved clinically relevant outcomes. The American Academy of Hip and Knee Surgeons, recognizing these study limitations and/or inconsistencies, has therefore concluded that `longer and more comprehensive follow-up of computer-assisted orthopedic surgery studies are needed to better understand the indications, limitations, and complications of the surgical procedure.` In this patients case, there is no indication of a special consideration such as severe femoral or tibial deformity that would warrant an exception to this conclusion.
Appeal type: Medical Necessity
Decision: Upheld

The representative of a 56-year-old female enrollee requested authorization and coverage of continued inpatient rehabilitation services for the treatment of the enrollees medical condition. The Health Plan denied the request indicating that the requested services are not medically necessary for the treatment of the enrollee status post stroke.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.