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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for genetic testing.  Findings:  Two of the three physician reviewers found that there is a lack of support for the services at issue in this clinical setting. Although the provider indicated that the patient has failed multiple medications, the records provided show that she was tried on Celexa and Zoloft, both in the selective serotonin reuptake inhibitor (SSRI) category. It does not appear that she was tried on serotonin-norepinephrine reuptake inhibitors or atypical antidepressants, such as Wellbutrin.  It also does not appear that electroconvulsive therapy was discussed. Studies have shown that clinically useful predictors in genetic testing are scarce for antidepressant therapy, with results being inconsistent. There is only marginal clinical association between enzyme system variants and drug metabolism, efficacy, and tolerability in the treatment of depression. The existing studies have indicated that there is no significant correlation between either genotypes or medication serum concentration and response to treatment. The current evidence does not support the use of genotyping when choosing an antidepressant, and even less is understood about its use in the treatment of anxiety disorders. Genetic testing lacks evidence-based research to show its efficacy in guiding the clinician towards choosing a medication regimen. Therefore, genetic testing was not likely to have been of greater benefit than other method of evaluating this patient. Final Result: The reviewers determined that the services at issue were not likely to be more beneficial for evaluation 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 psychiatry and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Nucynta 100 mg. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested medication. The patient has neuropathic pain. She has tried Lyrica, tramadol and Percocet. Additionally, she is allergic to morphine. Per the records, Nucynta has been beneficial for this patient in the past. The requested medication is medically reasonable in this patients case. Studies examined the role of tapentadol (Nucynta) in peripheral neuropathy and found it efficacious. Similarly, studies noted that tapentadol had some effectiveness in chronic regional pain syndrome. All told, Nucynta 100 mg is 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 anesthesiology with sub-specialty 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: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for treatment at a National Cancer Institute designated cancer center. Findings:  The physician reviewer found that Acute leukemia and their treatment are major emergencies in internal medicine. B-cell ALL is an aggressive disease where the standard of care is multi-agent chemotherapy followed by allogeneic hematopoietic stem cell transplant (allo-HSCT) for those with matched bone marrow. In this case, the patient was treated with hyper-CVAD and rituximab, which involves remission induction, intensification, followed by maintenance. At this time, he is a candidate for an allo-HSCT. Allo-HSCT eligibility depends upon human leukocyte antigen (HLA) match and social infrastructure. The social infrastructure is an essential component to determining eligibility since the post-transplant period requires almost daily evaluation for graft versus host disease and infectious complications. The patient has expressed a preference for treatment at the City of Hope since he lives 68 miles away from that facility versus over 100 miles from UCLA. However, the patients residence to UCLA consists of a commute of approximately one hour and 38 minutes, while his commute to the City of Hope showed is about one hour and six minutes. 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 internal medicine with sub-specialty certification in oncology and hematology 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 Supartz injection series for both knees. Per the medical literature, although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. The current evidence is limited, and guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate that the evidence is not conclusive. In light of the foregoing, viscosupplementation can only be recommended in individuals with a history of lasting benefit from prior injections, and in carefully selected cases where everything else has been tried, and the options are limited. In this case, the patient has a history of significant benefit from prior viscosupplementation. She has tried and failed other conservative treatments, with the alternative being bilateral total knee arthroplasties. Given the patients limited options and based on the current medical literature, the requested services are medically indicated. Therefore, Supartz injection series for both knees are medically necessary for the 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 orthopedic 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested pulsed radiofrequency neurolysis for treatment of the enrollees right-sided sciatic nerve pain. Findings: Three physician reviewers found that the request for pulsed radiofrequency neurolysis is not likely to be beneficial for treatment of the patients medical condition. Niemisto and colleagues assessed the effectiveness of radiofrequency denervation for the treatment of musculoskeletal pain disorders. The authors concluded that high quality random controlled trials with larger patient samples are needed as the current evidence is inconclusive. In this case, the requested procedure is likely to have limited efficacy for this patient due to the multiple pain generators present. The localization of pain generation to the posterior rami innervating the facet joints is not likely to include the full range of pain generation in this patient. Therefore, the requested procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: Three reviewers determined that the requested procedures 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 physician reviewers 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: Medical Necessity
Decision: Upheld

The patient is a 15-year-old female with a history of a pituitary lesion. The patient has been examined by a number of providers both in-network and out-of-network. A request has been made for authorization for another consultation with an out-of-network neurosurgeon. The Health Plan has denied the request on the basis that appropriate care is available in-network.No information has been presented in this case that demonstrates that it is medically necessary for the patient to obtain treatment from an out-of-network neurosurgeon. There is no evidence that the patients case involves a level of care or expertise that is not available in-network. The Health Plan is offering the patient appropriate providers for treatment of her medical condition. The patients care can reasonably be provided by an in-network neurosurgeon. Therefore, I have determined that the requested consultation 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:   An enrollee has requested acute inpatient psychiatric care for treatment of his behavioral health condition.   The physician reviewer found that acute inpatient psychiatric care was not medically necessary for treatment of the patients medical condition. There is a lack of documentation demonstrating that the patient was a danger to himself or others during the dates in dispute. The discharge summary indicates that the main goal of the treatment was to obtain the patients compliance with his medication regimen. Based on the documentation submitted for review, the services in dispute could have been provided at a lower level of care where the patient could have received education about his medication and could have been monitored as well. Therefore, 24-hour level of care was not medically necessary in this clinical setting. Based on the documentation provided,  acute inpatient psychiatric care was not medically necessary for treatment of the patients behavioral health 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 with sub-specialty certification in child and adolescent 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:   An enrollee has requested three dimensional (3D) breast tomosynthesis for evaluation of her risk for breast cancer with previous abnormal screening mammogram. Three physician reviewers found that in the medical literature, Skaane and colleagues reported that the use of mammography plus tomosynthesis in a screening environment resulted in a significantly higher cancer detection rate and enabled the detection of more invasive cancers. Thus, the literature does support the use of breast tomosynthesis over conventional mammogram due to improved cancer detection rate when used with standard mammographic imaging. Given these findings, breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: Three reviewers determined that the services at issue were medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications:  All three reviewers are board certified in diagnostic radiology and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 50-year-old female enrollee requested authorization and coverage of referrals for continued treatment with Dr. Nisly and Dr. Isaacs. The Health Plan denied the request indicating that the requested referrals are not medically necessary for treatment of the enrollees neurological symptoms.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plans denial on the basis that the requested referrals are medically necessary`.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of a minor enrollee has requested authorization and coverage for growth hormone (GH) treatment at pediatric dosage. Continued administration of GH therapy at pediatric doses is medically necessary for this patient until epiphyseal fusion or until the patients growth velocity decreases to less than two centimeters per year. After that time, the patient should be retested for adult GH deficiency. Thus, the patient meets the current criteria for continued administration of GH at pediatric doses for treatment of hypopituitarism secondary to cranial irradiation, as his epiphyses remain open and his growth velocity is greater than two centimeters per year. All told, the requested GH treatment at pediatric dosage is supported as medically necessary for treatment of this patients medical condition. 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 pediatrics with sub-specialty certification in pediatric endocrinology 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 61-year-old female enrollee has requested an out-of-network referral to a multidisciplinary functional rehabilitation program for treatment of complex regional pain syndrome.  Findings:  The physician reviewer found that Complex regional pain syndrome is a commonly encountered and managed pain diagnosis. Sympathetic blocks are a commonly performed interventional procedure in the management of complex regional pain syndrome. Any trained, board certified pain management specialist is capable of adequately managing complex regional pain syndrome and performing sympathetic blocks. A review of the record indicates the Health Plan has appropriate providers qualified to treat the patients condition. There is no evidence to support the need for treatment from an out-of-network specialist.
Appeal type: Medical Necessity
Decision: Upheld

The patient has Hepatitis C infection and began treatment with Pegasys in December 2003. His Hepatitis C viral load was less than 50 IU/ml in November 2004. The therapy was discontinued in January 2005 because of side effects. He resumed therapy with Pegasys in April 2005. Laboratory studies from May 2005 showed a viral load of 11, 500,000 IU/ml. The patient has requested authorization and coverage for continued treatment with Pegasys. The Health Plan has denied the patients request on the basis that Pegasys is not medically necessary.Review of the patients Hepatitis C PCR results indicates there was only one undetectable viral load in November 2004. Treatment with Pegasys clearly has not been effective for this patient. The goal of therapy is to eliminate the virus rather than to decrease the viral load. Given the patients inadequate response to therapy, continued use of Pegasys is not medically warranted. Therefore, I have determined the requested therapy is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

The patients parent has requested reimbursement and prospective authorization and coverage for eight hours per month of clinical team meetings. Although the patients behavior is described by the provider as a safety concern and the parent report on the Vineland Adaptive Behavior Scales score is listed as elevated in the most recent treatment authorization request, the data does not support these claims. The rate of the enrollees behavior is extremely low, suggesting they are not as problematic as described. The patient has also met or nearly met many of her goals. Due to the lack of significant problematic behavior and the skills that the patient has already acquired, the services at issue 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 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: Upheld

Nature of Statutory Criteria/ Case Summary:  The enrollees parent is requesting reimbursement for corrective orthotics. The enrollee is diagnosed with posterior tibial tendonitis in both legs, plantar fascial fibromatosis and pes plano valgus.  His condition causes pain, trouble walking or running, and is affecting his school and physical education. He reported intermittent pain with increased activity and his orthotics were modified with varus wedging. The podiatrists assessment was severe pes plano valgus deformity with complete collapse of the medial arch, significant forefoot abduction and calcaneal valgus on weight-bearing examination.  The podiatrist recommended continued use of the custom functional foot orthotics. Findings: The physician reviewer found that  according to the medical literature, in the population of patients with painful juvenile flexible flat feet, generic foot orthoses are sufficient; unless the enrollee presents with concomitant juvenile arthritis as well.  There is no evidence in the record this is the case with this enrollee or of prior use of over-the-counter orthotics that failed at providing symptom relief. Very few studies show that, in these cases of flatfoot deformity in the presence of chronic juvenile arthritis, the pain is reduced with the use of functional custom orthotics.  In these cases, studies have shown there is no benefit to custom orthotics over the generic orthotics.Final Result: The reviewer determined the requested service was not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The clinical reviewer is board certified in podiatry 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Botox injections for treatment of her migraine headaches. Findings:  The physician reviewer found that there is sufficient support for the requested services in this clinical setting.  The records support the diagnosis of chronic migraine.  Botox has been shown to be beneficial for preventive treatment of chronic migraine, and is U.S. Food and Drug Administration (FDA) indicated for this purpose.  She has had multiple medication trials, including antidepressant medication, anti-seizure medication, a muscle relaxant, as well as off-label use of Namenda as a headache preventive.  The current medical evidence supports the requested services 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 neurology 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 63-year-old female enrollee has requested Boniva (150mg once per month) for the treatment of her osteoporosis. Findings:  The physician reviewer found that it is not medically appropriate to require this patient to use weekly Fosamax as a prerequisite to taking monthly Boniva since she had been on Actonel weekly and demonstrated GERD symptoms. The use of Actonel 75 mg daily on two consecutive days sounds medically reasonable. However, she had been on Actonel 35 mg weekly for one year and had to stop taking it due to her GERD. This patient has responded positively to Boniva (150mg once/month) and she should continue taking this medication and dosage in light of the absence of her GERD symptoms with this regimen.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the anesthesia services provided during an endoscopy for evaluation of the enrollees colitis and polyps. Findings:  The physician reviewer found that the records do not document that this patient meets the criteria for use of monitored anesthesia services during endoscopy. Specifically, there is no evidence that the patient has a contraindication to conscious sedation or is at high risk of a complication from the use of conscious sedation. Moreover, there is no rationale presented to support an indication for monitored anesthesia services for a routine surveillance endoscopy in lieu of conscious sedation. Therefore, the monitored anesthesia services provided during an endoscopy were not medically necessary for evaluation of the patients medical condition. Final Result: The reviewer determined that the service at issue was not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in anesthesiology with sub-specialty 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.