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

A 57-year-old female enrollee has requested for an MRI of the right breast for evaluation of her history of left breast cancer. Findings:  Two physician reviewers found that there is adequate support in this medical literature for the requested diagnostic procedure in this patients case.  In this clinical setting, the utility of an MRI of the right breast has been established.  Given this patients history of left breast cancer, the requested diagnostic procedure may be beneficial in identifying potential disease in the contralateral breast.
Appeal type: Medical Necessity
Decision: Overturned

A fifty-eight year-old male with hypertension and chronic cough is requesting reimbursement for a CT scan.  Reviewers Findings:  The reviewing physician found that given the patients history, the CT scan at issue was medically necessary for evaluation of the patients medical condition.  The reviewing physician found that the Health Plan denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for compound medication (progesterone micronized 100% powder) provided Findings:  The physician reviewer found that the physician reviewer found that progesterone supplementation is routinely used in assisted reproduction to increase pregnancy success rates.  In this case, the patient was of an advanced maternal age and attempted pregnancy via embryo transfer. As noted by a study, there is little doubt that endometrial receptivity plays a major role in the success or failure of embryo implantation after in vitro fertilization (IVF). To optimize endometrial receptivity, it is common practice to administer a progesterone supplement during the luteal phase. Thus, treating this patient with micronized progesterone was medically appropriate. In this patients case, the provider recommended micronized progesterone suppositories, and there are no prescription suppositories currently manufactured by a pharmaceutical company.  The medical evidence supports the medication at issue in this clinical setting. All told, compound medication (progesterone micronized 100% powder) provided during the dates of dispute was medically necessary for the treatment of this patient.Final Result: The reviewer determined that the medication at issue was 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 digital breast tomosynthesis performed. Findings:  The physician reviewer found that the current medical evidence supports the service at issue in this clinical setting.  Breast tomosynthesis provides advantages to radiologists interpreting mammograms. This tomographic method often allows the reader to separate dense glandular elements from underlying mass/architectural distortion, resulting in a decrease in callbacks and increase in overall diagnostic accuracy and detection of small cancers compared to two-dimensional imaging alone.  Thus, the addition of breast tomosynthesis to the usual two-dimensional protocol was likely of greater benefit to the patient than had her examination been done with two-dimensional imaging alone.  Final Result: The 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: the 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: An enrollee has requested authorization and coverage for acupuncture services. There is a lack of support for the requested services in this clinical setting. Researchers performed a systematic review assessing evidence from randomized controlled trials on the effectiveness and safety of acupuncture and elecroacupuncture in patients with chronic neck pain. The authors noted that acupuncture and conventional medicine for chronic neck pain have similar effectiveness on pain and disability...When acupuncture was added onto conventional treatment it relieved pain better, and electroacupuncture relieved pain even more. In this case, this patient has received acupuncture services. Although she has reported that prior acupuncture services were beneficial, the provider failed to document that measurable and sustained objective functional improvement was obtained with previous acupuncture. Based on the records, the patient is not presenting with a flare-up of the condition or a re-injury. The documentation does not specify what further improvements would be achieved with acupuncture that could not be accomplished with a home exercise program. Therefore, acupuncture services 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 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested peroral endoscopic myotomy (POEM) for treatment of her medical condition.  Findings:  Three physician reviewers found that pneumatic dilation has been proposed for treating spastic disorders, and some success has been reported.  A caveat to this success is that it is unclear whether or not the patients benefited by pneumatic dilation would not be more properly categorized as having spastic achalasia or achalasia with esophageal compression, emphasizing the need for accurate manometric classification.  Researchers observed that pneumatic dilation was associated with a lower treatment response in patients with spastic achalasia compared with patients with achalasia with esophageal compression.  Botulinum toxin injection is a pathophysiologically attractive approach to treating patients with spastic disorders, and therapeutic trials suggest it can reduce chest pain.  Recently, POEM has been introduced to treat achalasia and several cases have been reported of jackhammer esophagus successfully treated by extended POEM.  However, powered prospective data is lacking to determine the role of POEM in the management of patients with spastic disorders.  Thus, the requested services are not likely to be of greater benefit than other treatment options. Final Result: Three 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: Experimental/Investigational
Decision: Overturned

The parent of a six-year-old male enrollee has requested array testing for evaluation of the enrollees epilepsy. Findings:  Two physician reviewers found that the use of chromosomal microarray testing now plays a central role in the evaluation and diagnosis of children with global developmental delay, cognitive delay, and autism spectrum disorders. Li and Andersson noted that most patients with mental retardation, autism spectrum disorder, developmental delay, or multiple congenital anomalies present in childhood and are cared for by pediatricians. Microarray-based cytogenetics should be the first-line test for these patients, except those suspected of having classic whole chromosome aneuploidy, such as Down syndrome or Turner syndrome. Miller and colleagues stated that, clinical geneticists, pediatric neurologists, and developmental pediatricians are increasingly ordering chromosomal microarray to obtain a genetic diagnosis for their patients with unexplained developmental delay, intellectual delay, autism spectrum disorder, and multiple congenital anomalies. All told, chromosomal microarray testing was likely to have been more beneficial for evaluation of this patients developmental delay than other available testing and has become the standard of care.
Appeal type: Experimental/Investigational
Decision: Upheld

A 19-year-old female enrollee requested for P-STIM (neuroelectrodes) for treatment of her fibromyalgia and chronic pain syndrome.  Findings:  Two physician reviewers found that peripheral nerve stimulation is not likely to be more beneficial in this setting where conservative therapy has failed to reduce the patients chronic pain condition. The patient does not have a diagnosis of neuropathic pain and there is lack of documentation to rule a psychological association to her pain. Thus, the requested P-STIM is not likely to be more beneficial for treatment of this patients medical condition than any available standard therapy.
Appeal type: Urgent Care
Decision: Overturned

A 28-year-old female enrollee has requested emergency services for evaluation of her pelvic pain. Findings:  The physician reviewer found that review of the submitted clinical documentation demonstrates that a prudent layperson would have sought immediate medical attention. In this case, the patient presented with acute symptoms of sufficient severity such that the absence of immediate medical attention could reasonably be expected to result in placing the patients health in serious jeopardy; serious impairment to bodily functions; and serious dysfunction of any bodily organ or part. The differential diagnosis of right lower quadrant pain includes several potentially life threatening disorders including hemorrhagic ovarian cyst, pyelonephritis and appendicitis. All told, the patients symptoms met prudent layperson criteria for emergency care.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for hydrocodone. A recent review from reported that, Anti-neuropathic analgesics may improve pain in IBS [inflammatory bowel syndrome], and deserve further, high-quality investigation, potentially considering parenteral administration and agents with minimal gastrointestinal motility effects. Researchers concluded that, Cognitive interventions such as cognitive behavioral therapy and hypnotherapy have demonstrated excellent results in IBS patients, but the limited availability and labor-intensive nature limit their routine use in daily practice. In patients who are refractory to first-line therapy, tricyclic antidepressants (TCA) and selective serotonin reuptake inhibitors are both effective to obtain symptomatic relief, but only TCAs have been shown to improve abdominal pain in meta-analyses. Furthermore, the Federation of State Medical Boards guidelines state that, opioid therapy for chronic pain that is not cancer-related, or part of palliative care or end-of-life care, only when non-opioid and non-pharmacological options have not been effective and maintain opioid dosage as low as possible and continue only if clear and objective outcomes are being met. In this case, the patient has chronic abdominal pain. The patients provider has recommended treatment with amitriptyline, Bentyl, and Imodium along with dietary changes and cognitive behavioral therapy (CBT) to assist with the patients anxiety and stress, which are noted to trigger her gastrointestinal symptoms. The guidelines do not report high quality data to support initiating chronic opioid therapy for this patients medical condition. Based on these findings, the requested hydrocodone is not medically necessary for treatment of this patient. 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 anesthesiology with subspecialty certification in pain 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for DME - Volara System and supplies. Findings:  The physician reviewer found that Lee and colleagues report that patients with bronchiectasis experience chronic cough and sputum production and require the prescription of airway clearance techniques. Mucus clearance programs are the mainstay of treatment of bronchiectasis. While the Volara System assists in mucus clearance, there is insufficient evidence to support the use of the Volara System over alternative standard mucus clearance programs including those combining flutter valves, hypertonic saline, nebulizer bronchodilators, and/or vest therapy. Per the medical evidence, airway clearance systems such as the Volara System appear comparable to other airway clearance techniques, including vest therapy. Whether prescribed within a stable clinical state or during an acute exacerbation, there is insufficient evidence to support the Volara System as more beneficial than other available standard therapies. Therefore, DME - Volara System and supplies are not likely to be more beneficial for treatment of the patients condition than any available standard therapy.Findings:  Three of the three physician reviewers found the requested DME - Volara System and supplies are not 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 device and supplies 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: Physician reviewers 1 and 2 are board certified in internal medicine with sub-specialty certification in pulmonary disease and in critical care medicine and are actively practicing. Physician reviewer 3 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

A 19-year-old male enrollee has requested for residential treatment center level of care for treatment of the his substance abuse. Findings:  The physician reviewer found that the use of the PHP level of care will allow for further integration into the communitys sobriety oriented activities (such as community based 12-step work), would be less disruptive to the patients occupation as a student, and would also allow him to be evaluated for the use of ongoing Buprenorphine/Naloxone Treatment (see Ann Fam Med. 2007) as an adjunct to his treatment for opiate addiction.
Appeal type: Medical Necessity
Decision: Overturned

An 89-year-old male enrollee has requested air ambulance transport for the treatment of him following a cerebral stroke. Findings:  The physician reviewer found that the standard of care in facilities outside of the US is not generally known. Within the United States, it would be the norm for a patient to be treated by a licensed physician, preferably one knowledge in neurovascular care, following a stroke. Because it is difficult to assess hospital and physician standards outside of the US, it is reasonable to transfer a critically ill patient.
Appeal type: Medical Necessity
Decision: Overturned

A 31-year-old female enrollee requested authorization and coverage of a hysterectomy and bladder suspension for the treatment of incontinence, pain and heavy bleeding. 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 overturned the health plans denial on the basis that the requested procedures are medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Harvoni for 12 weeks for treatment of his chronic hepatitis C virus genotype 1a.  Findings:  Three physician reviewers found that as per the American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) guidelines, all patients with chronic active hepatitis C are eligible for treatment and should be treated with U.S. Food and Drug Administration (FDA) approved antiviral therapy regardless of fibrosis score. Successful hepatitis C treatment results in sustained virologic response (SVR), which is tantamount to virologic cure, and is expected to benefit nearly all chronically infected patients. The fixed dose combination ledipasvir-sofosbuvir (Harvoni) is FDA approved for the treatment of chronic hepatitis C genotype 1 in both treatment-naive and treatment-experienced patients. Given this support, the requested 12 week course of Harvoni is medically necessary for treatment of this patients hepatitis C virus.   Final Result: Three reviewers 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 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: Experimental/Investigational
Decision: Upheld

A 22-year-old male enrollee has requested intravenous immunoglobulin (IVIG) treatment for treatment of his simple motor tics.  Findings:  Two physician reviewers found that based upon the available medical evidence, the superior efficacy of IVIG treatment in this clinical scenario has not been established. The association of streptococcal infection with basal ganglia disease, in particular, movement disorders remains the subject of debate. The clinical data do not support a cause-and-effect relationship for diagnoses such as PANDAS without substantially larger and carefully controlled clinical studies. While neuroimmune abnormalities may be present in individuals who carry a diagnosis of tic disorder and history of streptococcal infections, systematic studies offer no supportive evidence for neuroimmunologic dysregulation secondary to streptococcal infection. Given the lack of evidence that streptococcal infection results in neuroimmunologic dysregulation, the use of IVIG to treat an underlying immunologic defect that might give rise to these conditions is speculative and does not have sufficient scientific support use at this time.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 19-month old female enrollee has requested a custom remolding orthotic (pediatric/custom cranial device) for the treatment of the enrollees positional plagiocephaly. Findings:  The physician reviewer found that positional plagiocephaly and deformational brachycephaly are broad terms used to encompass abnormal head shape due to a wide variety of etiologies. Prenatal causes include resting of the fetal head against a hard surface (such as the mothers pelvis or the limb of a sibling in a multiple gestation pregnancy) for a prolonged period of time. Postnatal causes are more common and include congenital torticollis, vertebral anomalies, neurologic impairment, or forced sleep position (e.g., the American Academy of Pediatrics Back to Sleep recommendations). Brachycephaly is generally defined as a cephalic index of greater than 81%. This patient has a cephalic index of 89.5%. The most frequent cause is constant supine positioning during infancy. Presentation ranges from mild to severe. The most mild and even moderate cases may respond to mechanical adjustments and exercises. However, there are some cases that are severe and refractory to repositioning. Although positional head deformity is generally not a life-threatening condition, up to 10% of infants may have permanent deformity with subsequent complications (see Biggs). Because plagiocephaly and brachycephaly are extremely variable in etiology and presentation, strict guidelines for management are not possible. The American Academy of Pediatrics (AAP) published prevention and management guidelines for positional skull deformities in infants and found, Management of deformational plagiocephaly involves preventive counseling of parents, mechanical adjustments, and exercises  Skull molding helmets are an option for patients with severe deformity or skull shape that is refractory to therapeutic physical adjustments and position changes. Surgery is rarely necessary but may be indicated in severe refractory cases of deformational plagiocephaly or in patients with craniosynostosis. This patient was born with cranial asymmetry as a result of intrauterine positioning. Her cephalic index of 89.5% meets the definition of brachycephaly, and approximates the severe range of deformation. She has failed standard treatment recommendations for positioning. Her cranial asymmetry is exacerbated by plagiocephaly and macrocephaly, resulting in significant deformity. Based on the standard of care described above, the custom orthotic device was medically necessary and appropriate for this infant to prevent future complications and permanent deformity.