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

The parents of a two-year-old male enrollee have requested for speech therapy for treatment of the enrollees bilateral sensioneural hearing loss and speech/language disorder.    Findings:  The physician reviewer found that research has shown that early intervention for children with hearing loss makes a significant difference in speech and language skills in the early school years. The highest degree of success is with infants identified before six months of age. However, with active family involvement, even children identified in later infancy can show significant improvement in development of speech and language skills. Degree of hearing loss plays less of a role in predicting outcome than family participation and aggressive intervention. It is therefore essential that this young patient continue to receive speech and language therapy twice weekly. Furthermore, it is extremely important in therapeutic situations to continue with a provider with whom the child has established a rapport. This patient has shown improvement with his current provider. Timing is essential for children with hearing loss. Establishing a new relationship could waste valuable time, ultimately affecting the outcome of therapy.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Nucala 100 mg. Findings:  The physician reviewer found that in the peer-reviewed medical literature, a study reported that Nucala has not been demonstrated to improve health outcomes in patients with any eosinophil related disorder. Currently, Nucala is the subject of a phase 3 study. Standard therapies for treatment of this patients medical condition include Hydrea and vincristine. Overall, there is a lack of data supporting the safety and effectiveness of Nucala in this clinical setting. Thus, the requested Nucala 100 mg is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: Two of the three the reviewers determined that the requested medication is 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: Physician reviewers 2 of the 3 reviewers are board certified in internal medicine with sub-specialty certification in medical oncology and are  actively practicing.  And one physician reviewer is board certified in internal medicine with sub-specialty certification in pulmonary disease 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: Medical Necessity
Decision: Upheld

The patient is a 44-year-old woman with a diagnosis of infertility and four failed IUI cycles. It appears that she was then given ovum donation in two cycles, first via a fresh embryo transfer and then with a frozen embryo transfer. Both cycles resulted in pregnancy but ended in first trimester miscarriages. She was referred to a reproductive endocrinologist who initiated a workup for immunologic testing for recurrent pregnancy loss. A TH1:TH2 ratio was found to be elevated as well as CD19+ 5+ B-1 cells. IVIG therapy was recommended and given. The patient has requested reimbursement for IVIG therapy she received in September 2005 as well as prospective authorization for IVIG with a future pregnancy. The patient does have a diagnosis of recurrent pregnancy loss in the first trimester. The etiologies for this problem include chromosomal, uterine structural, ovulatory and immune factors. The treatment for immune factors and their efficacy is currently highly controversial. Although a few studies have shown modest benefit in properly characterized patients with repeated pregnancy loss, others have not. Thus, no clear efficacy has yet been shown. According to the 2004 Practice Committee Opinion of the American Society for Reproductive Medicine, IVIG treatment for recurrent miscarriage is an experimental treatment: For the management of recurrent spontaneous pregnancy loss IVIG is an experimental treatment. Based on the evidence available to date, there is insufficient data demonstrating the efficacy of IVIG in this clinical setting.For the reasons set forth above, 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: Experimental/Investigational
Decision: Overturned

A 51-year-old female enrollee has requested coverage for a pelvic floor stimulator for her stress urinary incontinence.Findings:  Two physician reviewers found that there is no question that behavioral therapies (i.e. bladder training, pelvic muscle rehabilitation, biofeedback) have a place in the treatment of incontinence and in fact are usually recommended as first-line conservative management prior to consideration of surgical treatment. With regard to efficacy, the pelvic floor stimulator was found in a randomized, controlled study to be an effective behavioral therapy in the treatment of incontinence. The pelvic floor stimulator has FDA approval and is commonly prescribed by physicians in the gynecological community.
Appeal type: Medical Necessity
Decision: Overturned

A 32-year-old female enrollee requested authorization and coverage for gastric bypass surgery. The health plan has denied this request indicating that the requested surgery is not medically necessary for treatment of the enrollees multiple obesity comorbid conditions including gastroesophageal reflux disease (GERD), reactive airway disease, stress incontinence, and degenerative joint disease.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the health plans denial on the basis that the requested procedure is medically necessary depending upon the results of a psychological evaluation.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested breast tomosynthesis for evaluation of her medical condition. Three physician reviewers found that peer reviewed literature supports the use of tomosynthesis in this clinical setting. Per Skaane and colleagues, the use of mammography plus tomosynthesis in a screening environment resulted in a significantly higher cancer detection rate and enabled the detection of more invasive cancers. Ciatto and colleagues state that integrated two dimensional and three dimensional mammography improves breast cancer detection and has the potential to reduce false positive recalls. For these reasons, the tomosynthesis used to screen this patient for breast cancer was likely to be more beneficial than any available standard therapy.  Final Result: Three reviewers determined that the service 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 reviewers are board certified in diagnostic radiology 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: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage to be prescribed both Tri-Mix and Quad-Mix. Findings:  The physician reviewer found that there is a lack of medical literature supporting the concurrent use of both Tri-Mix and Quad-Mix in patients with ED. Both Tri-Mix and Quad-Mix are compounded medications which are injected intracavernously to treat erectile dysfunction. Tri-Mix is a combination of three medications and Quad-Mix has one additional medication than Tri-Mix. Given the lack of support in the peer-reviewed literature, the request to be prescribed both Tri-Mix and Quad-Mix is not medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the requested medications 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 urology 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 53-year-old male enrollee has requested physical therapy services for the treatment of his degenerative disc disease. Findings:  The physician reviewer found that the patients PT progress notes demonstrates that he has had prolonged courses of PT without significant improvement. The patient had already had an appropriate course of PT for the management of his chronic low back pain.  Records during the timeframe in question demonstrate the patient had continued low back pain with pain ratings in the 3-5/10 range, very limited achievement of therapeutic goals and continued flare-ups. Thus, the medical necessity of the previous PT services is not established by the records. Furthermore, the evidence does not support the need for continued PT at this time, as it is not likely to result in further sustained clinical improvement in the patients pain level.
Appeal type: Experimental/Investigational
Decision: Upheld

Physician 1: The patient is a 50-year-old female with a two-year history of back pain. She has degenerative disc disease at L2-3, L3-4, L4-5 and L5-S1 and is status post percutaneous disc decompression at L3-4 and L4-5. The patients provider has recommended a single level artificial disc replacement at L5-S1. The Health Plan has denied this request on the basis that artificial disc replacement remains experimental.Artificial disc replacement remains an unproven procedure at this time. Long-term results are unknown and the procedures risks, long-term viability, and complications are unclear. Though a small study has been completed and short-term results are favorable, further studies and results are needed. As such, the procedure cannot be recommended at this time. Therefore, I have determined the requested procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld.Physician 2: The patient is a 50-year-old female with multi-level degenerative disc disease. Her provider is recommending artificial disc replacement at L5-S1. The Health Plan considers this procedure experimental and therefore, has denied authorization and coverage.The Health Plan is correct that the proposed procedure is considered experimental. The artificial disc is currently being investigated for single level disc replacement in the treatment of degenerative disc disease in the lumbar spine. Current data for single level disc replacement demonstrates a 63% short-term success rate; however, long-term outcomes are unknown and complications may be severe. Therefore, I have determined the requested procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld.Physician 3: The patient is a 50-year-old woman who has degenerative disc disease at L2-3, L3-4, L4-5 and L5-S1. She has attempted conservative measures without sustained relief of her back pain. In May 2005, she underwent percutaneous disc decompression at L3-4 and L4-5. She has now requested authorization for artificial disc replacement at L5-S1. The Health Plan has denied authorization for the requested procedure citing the lack of proven efficacy.The proposed procedure is experimental without established long-term safety and efficacy. Available data does not demonstrate an advantage to disc replacement over fusion. The long-term safety profile is unknown. There is no clinical indication demonstrating the proposed procedure is the best treatment option for this patient. There are other treatments available. For these reasons, I have determined the requested procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Accordingly, the Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for increased dosage of Stelara from every eight weeks to every four weeks. Current medical literature supports dose escalation of Stelara in this case. The patient has active disease symptoms. One large randomized controlled trial demonstrated the safety and efficacy for induction and maintenance of remission in patients with moderate-to-severe Crohns disease that was resistant to anti-tumor necrosis factor (TNF) therapy (Sandborn, et al.). Another study showed a 73% response in patients with anti-TNF-resistant Crohns disease, and 80% of responders maintained remission for one year (Kopylov, et al.). The mechanism of Stelara is different than that of anti-TNF medications, which this patient has failed (Tuskey and Behm). In an effort to address inadequate disease control, one study showed that a large proportion of patients were able to maintain response with dose escalation to 90 mg every four weeks (Kopylov, et al.). Multiple studies have shown that a majority of patients in whom Stelara dosing every eight weeks failed to control symptoms responded to dosing every four weeks (Wils, et al.; Battat, et al.; Khorrami, et al.). This patient has a severe disease that has required surgical intervention. Continuation of the current dose may result in further complications. For these reasons, an increased dosage of Stelara from every eight weeks to every four weeks is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Findings:  Three physician reviewers found an increased dosage of Stelara from every eight weeks to every four weeks is 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 increased medication dosage 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 subspecialty 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: Overturned

A twenty-seven year-old obese female with significant comorbidities is requesting authorization for laparoscopic adjustable gastric banding.  Reviewers Findings:The reviewing physician found that Lap-Band is as effective as other weight loss procedures and presents the least surgical risk.  The physician concluded that the Health Plan denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Overturned

The parent of a five-year-old male enrollee has requested occupational therapy for the treatment of the enrollees autism. Findings:  Three physician reviewers found that deficits in fine and gross motor skills and sensory integration dysfunction are common in this population of children and may lead to difficulties establishing relationships, navigating the educational system and ultimately navigating the work force. With its focus on developing motor planning skills and self-help skills, developing age-appropriate communication skills (written and functional), processing information and regulating the response to incoming information, occupational therapy is well-suited to affect positive change in children with autism spectrum disorder. The deficits identified and goals established for this patient are based upon conventional occupational therapy principles. Incorporation of sensory integration techniques to augment other occupational therapy techniques does not represent a deviation from standard practice. Occupational therapy is an integral part of treating children on the autistic spectrum with deficits in fine motor skills, balance and sensory integration, and it is medically indicated for treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a referral for treatment at a trauma based residential treatment center (RTC). Findings:  The physician reviewer found that the American Psychiatric Association (APA) practice guidelines note that indications for hospitalization include dangerous, impulsive behavior unable to be managed with outpatient level of care and complex comorbidity that requires more intensive clinical assessment of response to treatment. This patients symptoms are of sufficient severity to warrant RTC level of care as she has been unresponsive to outpatient and IOP levels of care. As noted in the medical literature, the authors discussed the promise of dialectical behavior therapy (DBT) for PTSD stemming from childhood abuse. The authors noted that DBT within an RTC program can help address the chronic nature of PTSD stemming from childhood abuse. As demonstrated in the records provided for review, the severity of the patients illness and failure of outpatient therapy supports the medical necessity of the requested treatment at a trauma based RTC. 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 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: Overturned

A 66-year-old male enrollee has requested a CT thorax, CT abdomen, MRI brain and MRI thoracic spine for an evaluation of his upper epigastric discomfort, back pain an headaches. Findings:  The physician reviewer found that this patient presented with pleuritic type chest pain and difficulty breathing.  The chest x-ray showed no acute disease, and the patients symptoms persisted following a trial of antibiotics.  These symptoms could be due to infectious or inflammatory disease of the chest, pulmonary embolism or pericarditis. CT scan of the thorax can evaluate for pulmonary embolism/infarct, small areas of infection not visible on chest x-ray and areas of inflammation within the lung and/or pericardium. With a normal chest x-ray and continued symptoms following antibiotic therapy, a CT of the thorax was medically appropriate. This patients symptoms of pleuritic type chest pain and epigastric pain radiating to the back can be a sign of aortic dissection or aortic aneurism involving the descending thoracic aorta and proximal abdominal aorta. The epigastric pain radiating to the back may be secondary to abnormalities of the pancreas, kidneys or biliary system. The accepted imaging study to evaluate the aorta, the pancreas, kidneys and biliary system is CT scan of the chest and abdomen. Therefore, the CT scan of the abdomen was medically necessary for evaluation of this patients medical condition. This patient had ongoing progressive headaches with no neurological symptoms or physical findings. This patient was noted to have sinus disease on prior plain films.  Headaches in older patients that are persistent and progressive are a red flag and should be evaluated promptly.  Headaches in older patients can be secondary to tumor, vascular abnormalities and intracranial bleeding.  MRI is more sensitive in evaluation of the brain, especially for vascular abnormalities. MRI of the brain can also evaluate for complications of sinusitis that can result in headaches. Thus, MRI of the brain was medically indicated and appropriate for evaluation of this patients medical condition.This patient had mid-back pain that radiated from the epigastric region.  He had no neurological symptoms or neurological findings on physical examination. Thoracic discogenic pain can present with pain that radiates to the trunk.  However, this patients thoracic spine symptoms could also be related to intra-abdominal or intra-thoracic abnormalities.  Treatment of patients with back pain with no history of cancer or recent trauma includes conservative therapy (i.e. physical therapy) for four to six weeks.  If the patients symptoms persist, further evaluation with diagnostic imaging is then indicated.  As this patient did not have any neurological symptoms or findings and had no history of cancer or recent trauma, MRI of the thoracic spine was not medically indicted at the time of this patients presentation.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for gene panel testing. Findings:  Three physician reviewers found that there are a number of serious medical disorders which are common in the Ashkenazi Jewish population. These are recessive genetic conditions. In order to reduce the incidence of these serious and lethal conditions in this population, genetic testing has been recommended by the American College of Obstetricians and Gynecologists. The results of this genetic testing allows the patient to make important reproductive decisions. Thus, gene panel testing was likely to have been more efficacious than other methods of evaluating this patient.Final Result: The 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: Physician reviewers 1, 2 and 3 are board certified in obstetrics and gynecology 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.