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

The patient has requested authorization and coverage for Epidural steroid injections. Epidural steroid injections have a clinically established role in the short-term management of low back pain when a patients pain is associated with symptoms of nerve root irritation and/or low back pain due to disc extrusions and/or contained herniations, and the pain is unresponsive to conservative treatment, including but not limited to pharmacotherapy, exercise or physical therapy. A systematic review by researchers found that lumbar epidural steroid injections were more effective for improved pain relief and function than injections without steroids. The American Society of Interventional Pain Physicians (ASIPP) concluded that for lumbar disc herniation with radiculitis, there is adequate evidence demonstrating short-term and long-term relief with local anesthetics with steroids. In a follow up statement, ASIPP reiterated that, the evidence is good for caudal epidural, interlaminar epidural, and transforaminal epidural injections with or without steroids in managing disc herniation or radiculitis. In this case, the patient presents with chronic back pain with radiation into the lower extremities that has persisted despite prior lumbar spine surgery. The patients physical examination is notable for positive straight leg test. The patient underwent a previous epidural steroid injection, with reported alleviation of pain and improvement in performing ADLs. Given these findings, the requested epidural steroid injections are medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in anesthesiology with subspecialty certification in pain management 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 a Dexcom G6 continuous glucose monitoring system (CGMS). Per the current consensus statement from the American Association of Clinical Endocrinologists (AACE) and American College of Endocrinology (ACE), the choice of diabetes therapies must be individualized based on the specific attributes of each patient and the available medications. Medication attributes that affect this choice include: antihyperglycemic efficacy; mechanism of action; risk of inducing hypoglycemia; risk of weight gain; other adverse effects; tolerability; ease of use; likely adherence; and safety or risk reduction in heart, kidney, or liver disease. Minimizing the risk of both severe and non-severe hypoglycemia is a priority. Self-monitoring of blood glucose is necessary in all patients taking insulin, with increased frequency of monitoring recommended for patients taking meal-time insulin. One safety measure for prevention of hypoglycemia is the use of a CGMS that provides real-time glucose data and alarms for hyperglycemic and hypoglycemic events. A 2019 meta-analysis by Ida and colleagues found that, compared with the self-monitoring blood glucose group, the CGMS group exhibited significantly lower hemoglobin A1c levels. This patient has diabetes mellitus type 2 with severe insulin resistance and multiple complications. He is being managed with continuous insulin infusion pump therapy, which requires the patient to make decisions based on glucose levels. This places the patient at risk for glucose fluctuations and hypoglycemia. In addition, he has neuropathy, nephropathy, sleep apnea and heart disease, which increases his risk of hypoglycemia. The real-time Dexcom G6 CGMS will likely decrease the patients episodes of hyperglycemia and hypoglycemia. Further, the Dexcom G6 includes a new alert that is triggered when an algorithm predicts that an estimated glucose value, allowing patients more time to act to avoid hypoglycemia. Therefore, the requested device, the Dexcom G6 CGMS is medically necessary to improve the management and control of this patients diabetes mellitus.Final Result: The reviewer determined that the requested equipment 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 diabetes, endocrinology 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: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for dosage escalation for Stelara 90 mg every four weeks. The peer-reviewed medical literature supports the requested dose escalation of Stelara to 90 mg every four weeks for management of this patients Crohns disease. The records document that the patients colonoscopy demonstrated findings consistent with active Crohns disease while on Stelara 90 mg every six weeks. Current data from clinical trials and studies have demonstrated the safety and efficacy of Stelara for induction and maintenance of remission in patients with moderate-to-severe Crohns disease that is resistant to anti-tumor necrosis factor (TNF) therapy (Tuskey and Behm). Kopylov and colleagues found that Stelara induced a 73% response in patients with anti-TNF-resistant Crohns disease, and 80% of the responders maintained remission for one year. Additional studies have shown that a majority of patients responded well to Stelara dosing every four weeks after failing to symptomatically improve with dosing every eight weeks (Battat, et al.; Khorrami, et al.). In this case, the patient experienced disease symptoms and objective active disease on colonoscopy while being treated with Stelara every six weeks. The American College of Gastroenterology (ACG) guidelines for the treatment of patients with Crohns disease supports medication dose adjustments in order to attempt to optimize therapy for patients with suboptimal control of symptoms. (Battat, et al.). Furthermore, continuation of dosing every six weeks or a change to another medication may result in complications for this patient. For these reasons, the requested dosage escalation for Stelara 90 mg every four weeks is medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested medication dosage 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: Experimental/Investigational
Decision: Upheld

A 69-year-old female enrollee has requested Mekinist (trametinib) in combination with docetaxel for treatment of her stage IV non-small cell lung cancer.  Findings:  Two physician reviewers found the requested medication is not likely to be more effective for this patient than other available treatment options. Mekinist is approved by the U.S. Food and Drug Administration (FDA) for BRAF positive metastatic melanoma. Although modest clinical trials have been performed, there is a lack of significant information or evidence to support the use of Mekinist for patients with NSCLC. Currently, there is a lack of sufficient outcome data from well-designed, peer-reviewed studies establishing the efficacy of Mekinist for treatment of the patients condition. Thus, Mekinist is not likely to be more efficacious than other modalities based on the available medical literature. As such, the requested medication is not likely to be more beneficial than other treatment alternatives in this enrollee's case.
Appeal type: Medical Necessity
Decision: Overturned

A 47-year-old female enrollee has requested a continuous glucose monitor system (CGMS) and the related supplies for the treatment of her type I diabetes. Findings:  The physician reviewer found that this patient suffers from hypoglycemia unawareness, which is clearly documented in the submitted records. She has needed emergency medical services to attend to severe cases of hypoglycemia that lead to coma and seizures. Therefore, the CGMS and related supplies are medically necessary for this patient with brittle, long-standing diabetes mellitus type 1 complicated by frequent hypoglycemic events. The device will alert the patient when a severe glucose excursion occurs during the unattended gaps, which may be asymptomatic and not detected by her standard handheld monitor. The CGMS will prevent the patient from progressing into a life threatening condition such as hypoglycemic coma or diabetes ketoacidosis. She has been unable to bring her HbA1c to any control for fear of hypoglycemia. In the long-term, with CGMS, the patient will likely be able to better control her diabetes mellitus, and prevent diabetic related complications, as documented by the Diabetes Control and Complications Trial Research Group trial.
Appeal type: Experimental/Investigational
Decision: Overturned

A female enrollee requested intravenous immunoglobulin (IVIG) infusion therapy for medical treatment of her Satoyoshi syndrome.  Findings:  Three physician reviewers found that despite Trileptal, the patients myoclonus remains disabling with upwards of 100 myoclonic jerks of the face and neck during the day. In this clinical setting, the next treatment option is IVIG infusion therapy. IVIG has been utilized empirically in a number of pediatric self-immune disorders for a number of years. There is support in the medical literature for treatment of Satoyoshi syndrome with IVIG (Asherson, et al). Therefore, based upon the medical literature and the documentation submitted for review, the request for IVIG is likely to be more beneficial for treatment than any other available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested a cesarean section for treatment of her medical condition. Findings:  The physician reviewer found that cesarean delivery on maternal request typically refers to a primary cesarean delivery performed because the patient requests this method of delivery in the absence of standard medical/obstetrical indications for avoiding vaginal birth.  In this setting, providers are encouraged to examine whether there are practice-based or facility-based changes that can remove some of the concerns that may contribute to a preference for planned cesarean delivery.  Providers should ensure adequate pain management, effective and supportive communication, and a strong commitment to training in low-intervention births.  Performing cesarean delivery on maternal request should be limited to cases in which the provider judges that it is sufficiently safe, given the specifics of the womans pregnancy and setting, and has had the opportunity for thorough and thoughtful conversation with the patient.  A womans right to be actively involved in choosing the route of her delivery is now widely accepted by clinicians and patients.  In a well-informed patient, performing a cesarean delivery on maternal request is considered medically appropriate.  All told, the requested cesarean section is medically indicated in this clinical setting.   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 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: Upheld

An enrollee has requested reimbursement and prospective authorization and coverage for platelet-rich plasma injections. This patient presents with complaints of persistent left shoulder pain. Clinical examination findings have been consistent with imaging evidence of subacromial bursitis and improvement. The patient is reportedly attempting to avoid or delay surgery. She has previously completed physical therapy and corticosteroid injections without sustained improvement. She underwent platelet-rich plasma injections into the subacromial space and medial scapular border. Current evidence-based medical literature does not support the use of platelet-rich plasma injections in the shoulder as safe and effective for rotator cuff pathology or shoulder pain and function. There is a lack of large volume, long-term outcome studies to support the use of these procedures for this patient. Therefore, the platelet-rich plasma injections to the left shoulder were not and 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 services at issue were not and 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, 2, and 3 are board certified in orthopedic surgery and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

A 54-year-old female enrollee has requested biofeedback therapy for treatment of her incomplete evacuation.  Findings:  Three physician reviewers found that Based upon the clinical information provided, the patients problem appears to stem from slow transit time causing constipation. Biofeedback therapy is not likely to be more effective than standard therapies in this setting. There are other available treatment options that are likely to be of greater benefit to this patient than biofeedback therapy.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested partial hospitalization program (PHP) services for treatment of her behavioral health condition. Findings: The physician reviewer found that based on the documentation submitted for review, the PHP services were not medically necessary for treatment of the patients behavioral health conditions. The medical records submitted for review do not demonstrate that the patient met criteria for treatment at the PHP level of care. The patient was extremely well motivated, compliant in treatment and was relatively self-sufficient. The level of motivation and compliance in patients is the main criterion that distinguishes the need for PHP versus intensive outpatient program (IOP) level of care. Both levels require that the patient be medically stable and not at risk of harm to self or others. In IOP, the patient would still have had access to individual therapy, group and nutritional counseling, but fewer hours per day. There is a lack of evidence in the medical records submitted demonstrating that the patient would have relapsed and needed re-hospitalization if she had been transitioned to a lower level of care. Given the above, the services at issue have not been established as medically necessary for treatment of the patients medical condition.  Final Result: The reviewer determined that the services at issue were not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: The reviewer is board certified in 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: Upheld

A male enrollee requested an epidural injection for medical treatment of his pain.  Findings:  The physician reviewer found that this patient was noted to have chronic cervical pain complaints, and he reported 15% pain relief from the previous epidural injection.  However, there was a lack of documentation indicating the patient had at least 50% pain reduction, had objective functional improvement, or had a decrease in medication use.  Moreover, the physical examination submitted for review failed to provide evidence of consistent radiculopathy to include abnormal sensation, motor strength, or reflexes along with a positive straight leg raise in a specific dermatomal or myotomal distribution to corroborate diagnostic studies.  Based on the clinical documentation, the epidural injection was not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 2-year, 5-month-old male has requested speech therapy for treatment of his speech delay.  Findings:  The physician reviewer found that there is a robust medical literature advocating speech therapy for autistic children and the scientific literature strongly supports speech therapy. Goldsteins article discusses the multiple techniques that can be successful in teaching autistic children to communicate. The paper by Turner and colleagues is a controlled study comparing autistic children, who did and did not receive speech therapy. Patients that did receive therapy had far greater communication skills than those that did not benefit from speech therapy. In addition, the report of the Speech-Language Hearing Association states that all autistic children can benefit from speech therapy as age, either early or late in life, is not a barrier to speech therapy. It is a medical necessity for this patient to receive speech therapy.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a three-year-old male with developmental apraxia of speech (DAS). His delay is estimated to be 12 to 16 months and motor skill delays are significant. The goals for this patient are improvement of motor, articulation, and verbal skills. Speech therapy was recommended twice a week for 9 to 12 months. At issue is whether speech therapy is medically necessary for treatment of the patients condition.An extensive review of the literature revealed no studies providing a clear diagnostic standard for DAS. Similarly, there were no outcome studies, which objectively demonstrated that speech therapy improves DAS. The DAS website also acknowledges there is limited research available, particularly outcome-related data. The study cited above demonstrates there is no clear definition of DAS or specific criteria for its diagnosis. In fact, many physicians question the validity of DAS as a diagnosis. Regardless of whether this is a developmental or a neurological condition, there is no medical indication for treatment given the absence of a diagnostic criteria or evidence of effective treatment modalities. DAS is more appropriately addressed as an educational issue. As such, given the information provided, there is no medical justification for past or future speech therapy services.Based upon the information set forth above, I have determined the therapy at issue was not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 12-year-old male enrollee has requested weekly cognitive behavioral therapy for treatment of the enrollees behavioral health conditions. Findings:  The physician reviewer found that although traditional treatments for autistic spectrum disorders include applied behavioral analysis, floor time, sensory integration and social-relationship based therapies, there is adequate evidence in the peer-reviewed literature to support the application of cognitive behavioral therapy for Aspergers disorder, particularly in regulating emotionality.  Additionally, cognitive behavioral therapy is a trusted intervention in the treatment armamentarium for patients with anxiety and affective disorders.  Thus, cognitive behavioral therapy is medically appropriate in this clinical setting.  Considering the clinical presentation, patient history and peer-reviewed medical literature, weekly cognitive behavioral therapy is medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for computed tomography (CT) angiography of the head and CT angiography of the neck. CT angiogram of the head and neck can be utilized to evaluate for stenosis, occlusion, vasculitis, aneurysm or additional structural abnormalities in the vessels of the head and neck. In the setting of neurologic deficit with suspicion for stroke, CT angiogram of the head and neck is supported by the American College of Radiology. In this case, the patient is at high risk for cerebrovascular disease given his history of hypertension and type 2 diabetes. The patient presented to his provider with complaints of increasing extremity weakness. The provider documented clinical suspicion for stroke or significant cerebrovascular disease. CT angiogram of the head and neck is medically necessary to evaluate for cerebrovascular disease in this patient.Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in diagnostic radiology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 27-year-old female enrollee has requested authorization for 30 days of inpatient drug rehabilitation services for treatment of her behavioral health problems.  Findings:  The physician reviewer found that the patients relapse potential was high due to chronic ADD/bipolar disorder. Even during her inpatient stay the patient showed reluctance to accept structured living placement for long-term structure and stability. Her impulsivity and reactivity remained evident throughout her stay in the inpatient chemical rehabilitation program. She was at high risk for relapse on drugs and psychiatric decompensation. She needed the structure of a therapeutic facility during the period at issue for stabilization.