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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for 20 hours of physical therapy utilizing the Wurn Technique. The treatment of intraabdominal adhesions in persons with a history of abdominal surgeries starts with conservative care such as bowel rest and decompression, but there is risk of recurrence because the underlying etiology, the adhesion, is not addressed. There is a lack of evidence supporting the benefit from any type of manual therapy for this condition and a lack of objective evidence derived from disinterested sources supporting the Wurn Technique, which is a proprietary, commercial technique. Researchers note that chronic pelvic pain and symptoms may result from various intra- and extra-pelvic etiologies. Researchers note that often no specific etiology can be identified for chronic pelvic pain in women, and that while pharmacotherapy, physical therapy modalities, and mental health interventions are often employed for treatment of these pains and/or symptoms, evidence-based therapies are limited. In this clinical setting, there is a dearth of high-grade evidence supporting the efficacy of physical therapy interventions. Therefore, 20 hours of physical therapy utilizing were not likely to have been more beneficial for treatment of the patients condition than any available standard therapy.Findings:  Two of the three physician reviewers found the 20 hours of physical therapy utilizing the Wurn Technique at issue was not likely to have been more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the services at issue were not likely to have been 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 reviewer 1 is board certified in physical medicine and rehabilitation and is actively practicing. Physician reviewer 2 is board certified in physical medicine and rehabilitation with sub-specialty certification in pain medicine and is actively practicing. Physician reviewer 3 is board certified in physical medicine and rehabilitation with sub-specialty certification in neuromuscular medicine 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: Urgent Care
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested emergency room services on an emergent or urgent basis.  Findings:  The physician reviewer found that review of the submitted documentation demonstrates that a prudent layperson would have sought immediate medical attention on the date in question. Upon review of the submitted medical records, the patient presented with severe worsening back pain and disability. Serious low back pain can lead to paralysis, bowel and bladder dysfunction. Cauda equina syndrome, spinal cord compression, compressive radiculopathy, spinal stenosis, paraspinal infections, vertebral collapse due to osteoporosis and malignancy, and abdominal aortic aneurysm can all occur without trauma. Based on the records submitted, the patients symptoms were of sufficient severity such that the absence of immediate medical attention could reasonably be expected to result in causing serious impairment to body functions or cause serious dysfunction to a body organ or part. Thus, the services at issue meet prudent layperson criteria for emergency care.  Final Result: The reviewer determined that the patients symptoms met prudent layperson criteria for emergency services. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: The reviewer is board certified in emergency 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for IVIG Gammaked 120 grams IV over five days every month x six cycles.  Findings:  The physician reviewer found that Churg-Strauss syndrome is a rare systemic and pulmonary vasculitis associated with asthma and eosinophilia. Treatment consists of corticosteroid therapy and immunosuppressive drugs such as cyclophosphamide and azathioprine. While there is a lack of large study data due to the rarity of the disease, current medical literature includes several case studies that report improvement in disease control in refractory patients to treatments such as glucocorticoids or cyclophosphamide.  A combination of pulse corticosteroids, pulse cyclophosphamide, and high-dose IVIG may be effective for the treatment of severe Churg-Strauss syndrome. Ikeda and colleagues report that an earlier add-on administration of adjunct mepolizumab and IVIG led to significant improvement in symptoms and prevention of flare-up of the disease. In a multicenter, double-blind, randomized clinical trial of 23 patients with Churg-Strauss syndrome, Koike and colleagues evaluated the effect of IVIG on residual peripheral neuropathy and reported that IVIG was found to improve neurological function via control inflammation in the peripheral nervous system. In this clinical setting, the potential clinical advantage with IVIG outweigh the risks of treatment and is likely to be more beneficial than the many systemic immunosuppressants that this patient has already tried and failed. Therefore, IVIG Gammaked 120 grams IV over five days every month x six cycles is 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 IVIG Gammaked 120 grams IV over five days every month x six cycles 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 service 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 reviewer 1 is board certified in allergy and immunology and is actively practicing. Physician reviewers 2 and 3 are board certified in dermatology 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

The patient is 38-year-old male that is quite allergic due to defined sensitivities confirmed by skin testing and an elevated IgE. On the other hand, his spirometry studies indicate minimal obstruction. The patient began Xolair injections in February 2004 and has since discontinued his Advair, Singular. Mescalor and albuterol inhaler.  The records also indicate that the patients requirement for prednisone began only after he discontinued Advair.  There is no information in the record suggesting that strict environmental control and/or a HEPA filter has been employed.  This patient has not met the prerequisites for Xolair administration.  He had no significant requirement for steroids when Xolair was initially prescribed in January 2004.  The record does not reflect an effort to eliminate allergens or that a HEPA filter has been employed.  Based on further review, it does not appear that other non-allergic etiologies, i.e., sinusitis or reflux, have been sufficiently explored. The patient is slightly overweight; therefore reflux should be ruled out.  In summary, the use of Xolair is not appropriate based on the spirometric studies and absence of adequate anti-asthmatic medications, i.e. Advair.  Furthermore, his physician has not advised environmental control nor pursued other etiologies.  Therefore, I have determined the requested medication is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

A 47-year-old female enrollee has requested authorization and coverage for a functional MRI for evaluation of the enrollee.    Findings:  The physician reviewer found that this patient has been diagnosed with conversion disorder.  Spells have been observed, and the differential includes non-epileptic events.  In the distinction of epileptic versus non-epileptic seizures, video EEG is appropriate for evaluation of spells of indeterminate origin.  In this patients case, video EEG was reportedly negative.  Functional MRI has not been proven as a tool for distinguishing conversion symptoms.  There is a lack of support in the medical literature for the use of a functional MRI in this clinical situation.  Although the literature suggests that functional MRI can demonstrate altered connectivity in varied brain regions, further research is needed to establish the role of functional MRI at this time.  All told, the requested functional MRI is not medically indicated in this patients case.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a 16-year-old male has requested coverage for past psychiatric acute inpatient level of care services for treatment of his major depressive disorder, severe, recurrent, without psychosis, generalized anxiety disorder, and Aspergers disorder.  Findings:  The physician reviewer found that in general, modern psychiatric practice aims to place patients in the least restrictive treatment setting, as community intervention settings optimize treatment gains.  With regard to this particular case, prior to the disputed service, the only treatment intervention was outpatient care.  The patient had not pursued treatment in more restrictive settings, such as intensive outpatient, partial hospitalization, or residential placement.  The submitted documentation does not demonstrate the medical necessity for the level of care rendered.  The patient had not failed an intermediate treatment setting, did not pose an imminent risk to self or others, and was not gravely disabled due to mental illness.  Thus, he did not require the comprehensive specialty psychiatric services afforded by the 24-hour acute setting.
Appeal type: Experimental/Investigational
Decision: Upheld

The parent of an 18-year-old male enrollee has requested authorization for neuro/biofeedback therapy and speech/language/hearing therapy for treatment of the enrollees attention deficit hyperactivity disorder (ADHD). Reviewers' Findings:The three physician reviewers found that Neuro/biofeedback therapy is not an accepted method of treating ADHD within the psychiatric community. Treatment of ADHD with neuro/biofeedback along with speech/language/hearing therapy is considered investigational. There are no controlled studies supporting the efficacy of these treatments and their administration is not consistent with the standard of care for the treatment of ADHD.
Appeal type: Medical Necessity
Decision: Upheld

A 58-year-old female enrollee has requested intensive outpatient treatment for treatment of her behavioral health diagnoses.  Findings:  The physician reviewer found that based upon the submitted documentation, the patient did not present any risk to self or others. The submitted medical records do not demonstrate abnormal laboratory results or vital signs. She was compliant and appeared to be motivated. In sum, the information submitted for consideration does not support the medical necessity for intensive outpatient program services for the date in question. The patient was well-motivated, and there is no evidence of acute impairment or significant likelihood of deterioration in functioning if she were to have been discharged from the intensive outpatient program as of that date. All told, intensive outpatient program services provided on the dates in question were not medically indicated. The patient could have been treated safely and effectively at the outpatient level of care during the dates of service at issue.
Appeal type: Medical Necessity
Decision: Upheld

A 25-year-old female enrollee requested authorization and coverage of an MRI to assess the disc position and status of the joints.  The enrollee has experienced pain,  stiffness and popping in her jaw.  The Health Plan denied the enrollees request indicating that the requested treatment is not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer upheld the health plans denial on the basis that the requested services are not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 29-year-old female has requested a power operated wheelchair for treatment of her tetraplegia.  Findings:  The physician reviewer found that based on review of the available records, the documentation supports the medical necessity of a power wheelchair for this patient. She is non-ambulatory and her upper extremity impairments significantly limit her ability to self-propel a manual wheelchair. A power wheelchair will significantly enhance her ability to perform mobility related ADLs. In addition, her home will accommodate a power wheelchair, and she should be able to effectively and safely use such a device. Her weight does not appear to be a limiting factor. Her ability to safely transfer in and out of a wheelchair under certain situations and stand with the use of a walker does not lessen the patients need for the device. All told, a power wheelchair is medically necessary given the patients impairments and disabilities
Appeal type: Medical Necessity
Decision: Upheld

The parent of a six-year-old male enrollee requested a wheelchair van lift for medical treatment of the enrollee, who has been diagnosed with cerebral palsy.  Findings:  The physician reviewer found that the criteria set forth by the Centers of Medicare and Medicaid Services to determine the medical necessity of durable medical equipment is considered the standard of care in this setting. According to the Centers of Medicare and Medicaid Services, durable medical equipment is defined as: equipment which can withstand repeated use; is primarily and customarily used to serve a medical purpose; is generally not useful to a person in the absence of illness or injury; and is appropriate for use in the patients home.  In this patients case, the requested device could withstand repeated use, and would not be useful to a person in the absence of illness or injury.  However, the device is for a vehicle and is not appropriate for use in the patients home.  There is no indication the device would serve a medical purpose.  As the wheelchair van lift is not for use in the home and no clear medical purpose was noted, the medical necessity for the proposed equipment is not established.  All told, the requested wheelchair van lift is not medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested digital breast tomosynthesis for evaluation of the enrollees medical condition.  Findings: Two physician reviewers found that Tomosynthesis is a technique that was developed as a problem solving adjunct to routine mammography. In this case, the presence of breast implants is not an indication for breast tomosynthesis. However, the patient has breast tissue that has been described as being heterogeneously dense. It is specifically those patients who have dense breasts that can benefit most from tomosynthesis. The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor. Therefore, in this clinical setting the breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: Two 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: All three 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 Otezla for the treatment of his plaque psoriasis. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication.  The medical records note chronic plaque psoriasis.  The Health Plan has denied coverage for Otezla due to a failure to demonstrate lack of efficacy or contraindications to preferred systemic treatments.  This patient has tried and failed therapy with a couple of medications and/or treatments.  However, there is no documentation that the patient has failed therapy with a number of other medications available for the treatment of this medical condition. Trial and failure of these agents is appropriate prior to initiation of Otezla. As such, there is a lack of support for the requested medication in this clinical setting. Thus, Otezla is not medically necessary for the 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 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: Upheld

The patient is a 14-year old female who injured her left wrist in an indoor rock climbing accident.  She fractured her radius and ulna and was in a cast for about three weeks. The patient had persistent pain after cast removal and was ultimately diagnosed with a triangular fibrocartilage complex (TFCC) tear.  Her parents took the patient to a non-plan orthopedic surgeon for a second opinion and he recommended arthroscopic wrist surgery with laser debridement of the TFCC.  The Health Plan is willing to provide arthroscopic wrist surgery performed by a hand surgeon, using the Arthrocare technique.  The Health Plan has denied authorization for the laser debridement procedure performed based upon their determination that it is not medically necessary.  TFCC debridement via wrist arthroscopy is essentially the same as laser debridement.  The expected outcomes are similar regardless of whether an Arthrocare radiofrequency probe is utilized or a laser technique. As such, the procedure recommended by the Health Plan is medically reasonable and appropriate. Therefore, I have determined the requested procedure is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for prophylactic extraction of third molars. Findings:  The physician reviewer found that age at loss of primary teeth and eruption of the succedaneous teeth can follow a wide normal range. However, it is typical that the primary second molars are lost close to age 12. In patients with mixed dentition, the primary molars are wider than the erupting premolars, which typically provides several millimeters of space in the arch. The panoramic image provided for review is a planar image and is not reliable to predict impingement of the adjacent teeth. With additional room in the arch to be gained upon loss of the remaining primary teeth, prophylactic third molar extraction is not indicated. While recommendations for extraction of wisdom teeth vary, current peer-reviewed dental literature provides a paucity of data to support prophylactic removal of asymptomatic third molars. As teeth numbers 1, 16, 17, and 32 demonstrate no pathology, the requested prophylactic extraction of third molars is not medically necessary for treatment of the 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 dentistry 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 laboratory gene analysis tests (CPT 81241-90) (CPT 81240-90).Findings:  The physician reviewer found that deep vein thrombosis (DVT) and pulmonary embolism may be caused by hereditary thrombophilias. It is important to know when there is an increased risk, especially in situations of pregnancy, estrogen therapy, and prolonged immobility such as surgery, long car trips, or long airplane flights, as these complications may be prevented by appropriate interventions. Connors notes that inherited thrombophilias have been reported to be associated with an increased risk of VTE in these sites, particularly thrombophilias due to the prothrombin gene mutation or factor V Leiden. In this case, the records noted a history of left lower extremity DVT. The records noted that the patient was started on Lovenos while hospitalized and later switched to Eliquis. The provider noted the possibility of lifelong anticoagulation therapy with Eliquis. In choosing between lifelong anticoagulation therapy versus discontinuing therapy, a work-up including hypercoagulability testing would assist in the decision-making process. Therefore, laboratory gene analysis tests (CPT 81241-90) (CPT 81240-90) were likely to have been more beneficial for evaluation of the patients condition than any available standard therapy.Findings:  Two of the three physician reviewers found the laboratory gene analysis tests (CPT 81241-90) (CPT 81240-90) at issue were likely to have been more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the services at issue were likely to have been 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 sub-specialty certification in hematology 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.