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

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for individual therapy. The National Autism Center has identified effective, emerging, and unestablished treatments for autism spectrum disorder. Cognitive behavioral therapy (CBT) to treat anxiety symptoms in children with high functioning autism is an established treatment, providing support for the use of psychotherapy. The research supporting CBT as an established treatment has not included patients younger than age seven. Ung and colleagues conducted a meta-analysis on the effects of CBT on anxiety in patients ages 7-17 with high functioning autism. The authors found that CBT was effective in treating patients with autism and anxiety. According to Helps, the current data supports family psychotherapy in this clinical setting. Further, the Behavior Analyst Certification Board states that family involvement is a critical part of applied behavior analysis and that a consultative approach to therapy is appropriate for young patients with autism. In this patients case, the goals listed in the treatment plan are consultative in nature and involve the collaboration of the provider and his family. The records do not support an indication for individual therapy. Given these findings, the requested individual therapy is not medically necessary for 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 a 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: Overturned

The patient is a 53-year-old female with right lower extremity weakness and numbness. The patient reports that she requires help from her husband to get to her medical appointments. Prior to her illness she was independent in her daily living activities, and had complete mobility with shopping, driving, etc. A home physical therapy evaluation was performed in June 2006. The patient has requested authorization and coverage for home health physical therapy, which has been denied by the Health Plan on the basis that it is not medically necessary.The submitted documentation indicates the patient has gait disturbance. She had an evaluation for physical therapy in her home in June 2006. She was noted to be independent with mobility but had impaired balance, impaired right lower extremity sensation, decreased right lower extremity (1-3 of 5), and was also noted to walk with a front-wheeled walker. Based upon the evidence provided, the patient requires home physical therapy as she remains homebound at this time. She is unable to leave her home without assistance from another person. She has experienced a decline in her level of function as a result of illness and therefore requires physical therapy to improve her right lower extremity strength and balance and regain her prior level of ambulation without requiring assistance. Therefore, I have determined the requested therapy is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for bilateral genicular blocks and ablation of the knees. The records provided for review document that this patient has a history of bilateral knee pain that has not substantially improved despite treatment with physical therapy, medications, and a Euflexxa injection. Fogarty and colleagues found that, there is moderate-quality evidence that fluoroscopically guided genicular radiofrequency ablation is effective for reducing pain associated with knee osteoarthritis at minimum of six months. Guler and colleagues reported that ultrasound-guided genicular nerve block is more effective than physical therapy alone in the treatment of knee pain secondary to chronic osteoarthritis. This patients bilateral knee osteoarthritis has not substantially improved despite treatment with medications, physical therapy, and hyaluronic acid injection. There are adequate data in the medical literature to support the safety and efficacy of the requested genicular nerve blocks and ablation for management of this patients bilateral knee pain. Therefore, the requested bilateral genicular blocks and ablation of the knees are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings: Two of the three physician reviewers found the requested bilateral genicular blocks and ablation of the knees are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewer 1 is board certified in orthopedic surgery and is actively practicing. Physician reviewer 2 is board certified in orthopedic surgery and is actively practicing. Physician reviewer 3 is board certified in orthopedic surgery 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Lantus Pen. Findings:  The physician reviewer found that the request for the Lantus Pen has been established as medically necessary for treatment of the patients medical condition. Lantus is a once-daily, long-acting insulin analog that is specifically designed to provide basal insulin requirements. There is ample evidence in the peer-reviewed literature demonstrating that treatment with Lantus is associated with A1c reduction as well as decreased glycemic variability when compared to NPH insulin. In addition, retrospective studies have shown that switching patients from NPH insulin to Lantus insulin leads to significant improvement in glycemic control. Therefore, the request for Lantus Pen is medically necessary for the treatment and management of the patients diabetes. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism 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 54-year-old female enrollee has requested a nephrologist for treatment of her decreasing serum creatinine and glomerular filtration rates. Findings:  The physician reviewer found that this patient has mild chronic kidney disease (CKD) based on the GFR measurements provided for review. This determination is based on the guidelines published by the National Kidney Foundation, as the absence of hematuria or proteinuria argues against an active glomerular process. As stated by the authors of UpToDate reference cited above, Patients with CKD should be referred to a nephrologist early in the course of their disease, preferably before the plasma creatinine concentration exceeds 1.2in womenor the eGFR is less than 60 mL. As this patient does not have an average GFR measurement below 60 mL, referral is not clinically indicated at this time. Further evaluation and monitoring by the patients primary care physician is medically appropriate in this setting.
Appeal type: Experimental/Investigational
Decision: Upheld

A 54-year-old male has requested radiofrequency ablation of the esophagus for treatment of his Barretts esophagus.  Findings:  Two physician reviewers found that the patient presents with a 30-year history of gastroesophageal reflux disease.  The medical records noted that the patient was found to have Barretts esophagus on esophagogastroduodenoscopy.  A recent  pathology report noted intestinal metaplasia with no dysplasia.  The submitted documentation fails to demonstrate the superior effectiveness of the requested services in this patients case.  Per the current standard of care, if the Barretts esophagus has any form of dysplasia, then radiofrequency ablation may be a reasonable option.  In the setting of dysplasia, surveillance is not recommended and active therapy, including radiofrequency ablation, may be indicated.  In this patients case, there was no evidence of dysplasia.  Based upon the medical records, active surveillance is appropriate in this setting.  All told, the requested radiofrequency ablation of the esophagus is not likely to be more beneficial than other treatment options.
Appeal type: Experimental/Investigational
Decision: Upheld

Physician 1The patient is a 62-year old man who is requesting percutaneous lysis of epidural adhesions. He has chronic lumbar pain and is status post lumbar laminectomy. The Health Plan has denied authorization and coverage for the requested procedure on the basis that it is considered investigational.The requested procedure has no long-term proven benefit. There are no long-term, prospective studies demonstrating that the requested procedure is effective. The submitted operative reports reveal epidural injections were performed; it is unclear from the reports exactly what is considered the percutaneous lysis portion of the procedure. While epidural injection may be effective for patients such as this patient, the lysis of adhesions is not necessary or recommended. Therefore, I have determined that 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 2This patient is a 62-year-old man who has been experiencing back pain secondary to laminectomy syndrome. He is requesting percutaneous lysis of epidural adhesions. The patient indicates this procedure has been performed approximately twice a year for the past several years. The Health Plan has denied authorization and coverage for this request on the basis that lysis of adhesions is considered experimental.The requested procedure is not the standard of care and is of unproven efficacy. There are no class I data to support lysis of adhesions at this time. The patient is likely to receive greater benefit from standard therapies. Therefore, I have determined that 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 3The patient is a 62-year-old man with a history of post-laminectomy syndrome. He is requesting percutaneous lysis of epidural adhesions. The Health Plan has denied authorization and coverage for the requested procedure on the basis that lysis of adhesions is considered experimental.Review of the medical literature reveals the requested procedure is without established efficacy. There are no prospective criteria indicating that lysis of adhesions has long-term clinical benefit. Thus, it has not been established that the requested procedure results in a superior outcome to standard therapies. Therefore, I have determined that 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.
Appeal type: Experimental/Investigational
Decision: Upheld

A 47-year-old male enrollee has requested multi-level disc replacement surgery with Pro Disc-C for the treatment of his cervical stenosis. Findings:  Three physician reviewers found that multi-level artificial disc replacement remains an unproven procedure. Currently, artificial disc replacement has been approved only for single-level. Given the lack of documentation of the success and completion rates of multi-level disc replacement, and the absence of long-term prospective studies, multi-level disc replacement cannot be recommended. Standard surgical interventions would have been more appropriate in this clinical setting.
Appeal type: Medical Necessity
Decision: Overturned

The patient has requested authorization and coverage for Xifaxan 550 mg. The records provided for review document that this patient has irritable bowel syndrome, diarrhea-predominant (IBS-D). The patients provider has recommended treatment with Xifaxan. Xifaxan is U.S. Food and Drug Administration (FDA) approved for the treatment of patients with IBS-D. In addition, Xifaxan has been demonstrated to be safe and effective for the treatment of IBS-D in randomized placebo-controlled trials (Schoenfeld, et al.; Lembo, et al.). Moreover, the American College of Gastroenterology (ACG) guidelines state that Xifaxan is effective for use in patients with IBS (Ford, et al.; Cangemi and Lacy). Overall, the peer-reviewed medical literature and current guidelines support the use of Xifaxan dosed at 550 mg three times daily for 14 days in this patients clinical setting. For these reasons, the requested Xifaxan 550 mg is supported as medically necessary for the 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 certification in gastroenterology 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

An 18-year-old female enrollee requested reimbursement for outpatient psychotherapy for treatment of the enrollee, who has been diagnosed with bipolar II disorder, major depressive disorder, and attention deficit/hyperactivity disorder. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  Current practice is focused on aggressive treatment of depression, particularly in the acute phase of the illness, followed by less frequent services in the maintenance phase to foster patient autonomy and recovery.  Thus, it is not uncommon for transient sessions two to three times weekly to be clinically appropriate, particularly since psychotherapy is the cornerstone of treatment for affective disorders.  However, the presentation of this case lacks a comprehensive psychiatric assessment or progress notes that review the patients history, previous interventions, treatment plans, therapeutic goals, current formulation, and diagnostic assessment to justify sessions at increased frequency.  Further, the documented clinical interventions during the dates of service at issue provide neither a diagnosis nor a link to a comprehensive plan of care aimed at a specific desired therapeutic end state.  In the absence of such documentation, the medical necessity of the services at issue is not established.  All told, the outpatient psychotherapy provided was not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for laser treatment for her varicose veins.  Findings: The physician reviewer found that the request for laser treatment of varicose veins is not medically necessary for treatment of the patients medical condition. Ulceration and hyperpigmentation are recognized complications of sclerotherapy. In general, hyperpigmentation lightens with time and most commonly topical agents are applied. The current data suggests less than a quarter of lesions lighten with laser therapy. Moreover, there are a lack of randomized trials supporting the use of laser treatment for the patients medical condition. As such, the request for laser treatment of varicose veins is not medically necessary. Final Result: The reviewer determined that the requested service is not medically necessary or reconstructive in nature for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in vascular 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: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Dupixent 300 mg/2 mL syringe. Atopic dermatitis is an immunologic disorder that primarily involves TH2 helper cell dysfunction per a study. Dupixent is a monoclonal antibody targeted therapy that significantly reduces disease and its associated symptoms. Dupixent is U.S. Food and Drug Administration (FDA) approved for the treatment of patients with atopic dermatitis. A study found that Dupixent improved clinical responses in adults with moderate-to-severe atopic dermatitis in a dose-dependent manner, without significant safety concerns. Moreover, Dupixent has been shown to be more effective than methotrexate and other immunosuppressive medications in this clinical setting. The available documentation supports Dupixent as appropriate for treatment of this patients chronic atopic dermatitis in conjunction with topical agents and non-pharmacokinetic measures. Therefore, the requested Dupixent 300 mg/2 mL syringe is 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 dermatology 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 intensive outpatient program (IOP) for 30 to 60 days for treatment of the enrollees autism spectrum disorder and global developmental delay. Findings:  The physician reviewer found that there is sufficient support in the medical literature for the requested services in this clinical setting. Recent medical literature supports early intervention services for children who are diagnosed with an autism spectrum disorder. In a recent article, children enrolled in a multidisciplinary team approach such as the Pediatric Minds Early Childhood Treatment Center demonstrated significant gains in overall functioning that were sustained on follow up evaluations two years later. Occupational therapy has also shown to be beneficial in the treatment of autism, addressing postural control and adaptive skills for long term independence. Lastly, the use of cognitive behavioral therapy has also been shown to be beneficial in the care of children with autism, successfully addressing common problems such as feeding difficulties. Given the proven benefit of early intervention in autism, coupled with the aforementioned efficacy of speech, occupational and cognitive therapies, IOP services are  medically appropriate and should be approved at the recommended rate of three hours per day, five days per week for 30 to 60 days. 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 pediatrics with sub-specialty certification in developmental-behavioral pediatrics and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for inpatient care services at Providence St. Joseph Medical Center. In this case, the patient presented with gastroparesis and malnutrition. She had a gastrojejunostomy tube with appropriate placement confirmed on computed tomography (CT) scans, with stable neurologic and hemodynamic statuses. Her future treatment options included deep brain stimulation surgery. The patients chronic pain was managed with a medication regimen. Given that the patient was medically stable, without advanced procedures or monitoring, and without complications or unstable comorbidities, the services at issue were not and are not medically indicated. Therefore, inpatient care services at Providence St. Joseph Medical Center were not and are not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the services at issue were not and are 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 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 35-year-old male enrollee has requested for Cialis 2.5mg daily for treatment of his erectile dysfunction. Findings:  The physician reviewer found that the current medical evidence does not support the daily use of Cialis in this clinical setting.  Cialis is indicated for the treatment of erectile dysfunction.  However, Cialis is not indicated for the treatment of loss of libido, orgasmic dysfunction, or loss of genital sensation. All told, Cialis 2.5mg daily was not and is not medically necessary in this patients case.