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

Nature of Statutory Criteria/Case Summary: A 48-year-old female enrollee has requested reimbursement and prospective authorization and coverage for skilled nursing facility (SNF) services for treatment of the enrollees malignant neoplasm of breast and cerebellar degeneration. Findings:  The physician reviewer found that the records provided for review do not demonstrate that the patient has needs for SNF services. The documentation does not reveal complex wound care, enteral feeds or ventilator dependence. The patient does not require skilled nursing services to prevent a deterioration in her condition or skilled nursing services to establish a safe and effective maintenance program. The patient does not require skilled therapy services on a daily basis or skilled nursing services on a daily basis. The patient has been limited by severe dizziness and fatigue with very slow progress in therapy. Therefore, she would not be expected to make measurable gains within a reasonable and predictable period of time or require inpatient skilled daily therapy to prevent deterioration with mobility and/or activities of daily living or establish a safe maintenance program. The patients therapy needs can be met at a lower level of care such as custodial care. Thus, the SNF services were not and are not medically necessary for treatment of this patients medical condition.  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 overturned. Credentials/Qualifications: The reviewer is board certified in physical medicine and rehabilitation with sub-specialty certification in neuromuscular 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 23-year-old female enrollee has requested spinal fusion surgery at L5-S1 for treatment of her lumbar degenerative disc disease at L5-S1 with grade 1 spondylolisthesis.   Findings:  The physician reviewer found that the clinical records document an isthmic type of L5-S1 spondylolisthesis with degenerative changes at L5-S1 without disc herniation. The incidence of spondylolysis and spondylolisthesis is approximately 6% in the general population and usually occurs at L5-S1 as it does in this patient. Ninety percent of cases occur at L5-S1. There is a higher prevalence in women. While the progression of the spondylolisthesis can occur in younger patients, there may be a gradual stabilization and diminution in the rate of progression in older patients except in the case of degenerative spondylolisthesis. Treatment recommendations published by the American Academy of Orthopaedic Surgeons and accepted as standard of care, state that spondylolysis and isthmic spondylolisthesis would likely benefit from a nonsurgical treatment protocol with physical therapy, home-based strengthening programs, weight reduction and activity modification with possible injection therapies including epidural injections, facet blocks and pars injections. Klein et al. reported a meta-analysis of nonoperative treatment in children and young adults with grade I spondylolisthesis. This analysis suggested that 83.9% of patients treated non-surgically had a successful clinical outcome after at least one year. Bracing was seen not to influence outcomes. There was success in conservative care referencing clinical parameters. Pars interarticular defects themselves did not heal. In the study authored by Girardo et al. (a retrospective study on the outcome of uninstrumented posterolateral fusion in this population group), satisfactory results were documented in as many as 94% of patients. Positive results correlated well to the rate of successful fusion. All told, multiple studies are available with varied results. Thus, currently available data does not allow for a single optimal surgical approach to be identified. The appropriateness of spinal fusion for patients with low grade isthmic spondylolisthesis, such as is present in this patient, remains the subject of debate.In this patients case, the surgical instrumentation and fusion is not likely to have a more predictable outcome than a comprehensive conservative treatment program. There is no indication in the case review that such a program has been instituted, in spite of references made to the use of a brace. In summary, an immediate surgical intervention is not the standard of care in this setting, nor is it likely to be as effective as a well organized conservative treatment program with further observation and further documentation of the presence or progression in structural instability patterns.
Appeal type: Experimental/Investigational
Decision: Upheld

A 34-year-old female enrollee has requested for a 3-D ultrasound for evaluation of her condition.  Findings:  Three physician reviewers found that real-time 3-D and 4-D ultrasound is a technical advancement that involves computer-generated images of the fetus shown in three-dimensions. The resulting picture provides almost life-like images of the fetus. For obvious reasons, this technology is a tremendous patient-pleaser. However, this technology has not been definitely established as superior to conventional 2-D ultrasound in providing the diagnosis of fetal abnormalities. In fact, some studies have even suggested it is inferior to assessing basic cardiac views of the fetal heart. Thus, the clinical application and wide-spread use of 3D ultrasound for the routine assessment of a fetus is unclear.
Appeal type: Experimental/Investigational
Decision: Upheld

A 51-year-old female enrollee has requested a positron emission tomography (PET) scan with computed tomography (CT) attenuation for an evaluation of her swollen lymph nodes. Findings:  Three physician reviewers found that in this case, a PET/CT is not clinically indicated at this time.  From an imaging standpoint, it would be best to first establish a diagnosis.  Chills and fevers might raise the possibility of an infectious/inflammatory etiology, or lymphoma, rather than recurrent myoblastoma, especially after so many years.  Along with appropriate medical work-up, CT of the neck, chest, pelvis, and abdomen would be logical and may point to another area that could be biopsied.  Once a diagnosis is established, then PET/CT could be considered for staging, if indicated.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:   An enrollee has requested Zyvox for treatment of her medical condition.  The physician reviewers found that the submitted documentation fails to demonstrate the medical necessity of the requested medication.  This patient had intraoperative culture results which indicated the presence of a Staphylococcus epidermidis infection that is not resistant to either oxacillin or vancomycin.  Per the current medical evidence, indications for the use of linezolid (Zyvox) do not include use for nonresistant strains of this infection.  In addition, this patient was recently on a three-week course of this medication and has continued symptoms.  There is some question regarding whether the use of antibiotics with chronic rhinosinusitis is always indicated, and this patient does not appear to be on sufficient allergy medication regimen.  All told, the requested medication Zyvox  is not medically indicated 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 otolaryngology 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 57-year-old female enrollee has requested for a transcutaneous electrical nerve stimulation (TENS) unit for treatment of her persistent genital arousal disorder. Findings:  The physician reviewer found that persistent genital arousal disorder is a medical condition without known pathological cause, and rather is a diagnosis of exclusion.  There is a lack of support in the medical literature for the requested device in this clinical setting.  Basson and colleagues published an update of recommendations pertaining to the diagnosis and treatment of womens sexual dysfunctions.  They reported that a comprehensive assessment of medical, sexual, and psychosocial history is recommended for diagnosis and management.  The authors concluded that there remains a need for more research and scientific reporting on the optimal management of womens sexual dysfunctions, including multidisciplinary approaches.  Dubinsky and Miyasaki performed a systematic literature review to determine if TENS units are efficacious in the treatment of pain in neurological disorders.  The authors concluded that more rigorous studies are needed to determine the efficacy of the device.  All told, the requested TENS unit is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a two-year, five-month-old male enrollee has requested authorization and coverage for speech therapy. The Health Plan has denied this request indicating that the requested therapy is not medically necessary for treatment of the enrollees speech delay.  Findings:  The physician reviewer found that this patient has an identified delay in expressive speech of approximately 68% and a delay in receptive speech of 28%. Consistent with the recommendations in the medical literature, speech therapy is indicated for patients who present with any delay greater than 25%. Extensive review of the literature including meta-analysis by Law and colleagues noted a positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulty. Further, Volmar and Weisner noted that treatment for language disorders is predicated primarily on the childs language profile and level of communication skills. Overall, approximately 50% of children delayed at 2 years catch up to peers by 3 years of age while children with mild to moderate disorders are most likely to resolve their delay. In addition, the authors found that children treated with early intervention services with parental interaction and teaching demonstrated stronger language skills than those who did not receive early intervention. Moreover, children who participated in speech and language therapy showed better improvement when compared to their untreated peers. Gallagher and Chiat evaluated speech and language interventions for 24 preschool children with specific language impairment. The authors reported statistically greater improvement with intensive direct speech and language therapy delivered by speech and language therapists over an 8-month period when compared to no intervention or nursery-based intervention. This patient continues to display expressive and receptive language impairment with decreased acquisition of language skills. Based on the foregoing discussion, the requested speech therapy is medically necessary in the treatment of this patients medical condition and should therefore be approved.
Appeal type: Experimental/Investigational
Decision: Upheld

Findings:  The physician reviewer found that An enrollee has requested authorization and coverage for Qulipta. Calcitonin gene-related peptide (CGRP) plays a crucial role in migraine pathophysiology and has been established as an important target for both preventive and acute treatments (Edvinsson, et al.). Per the American Headache Society (AHS), Aimovig is an injectable monoclonal antibody targeting the CGRP receptor. Ubrelvy is an oral CGRP inhibitor approved by the U.S. Food and Drug Administration (FDA) in 2019. Ubrelvy is indicated for the acute treatment of migraine with or without aura in adults. In a case report study, Mullin and colleagues concluded that concomitant use of Nurtec and Ubrelvy may involve additive effects and may be generalizable to other combinations of anti-CGRP agents with distinct molecular targets. In this case, the patient has a history of migraines that have not responded to multiple oral abortive and preventative medications. However, there is a lack of studies available that suggest the addition of Qulipta to a preventative anti-CGRP receptor antibody provides any clinical benefit. Therefore, the requested Qulipta is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings:  Three of the three physician reviewers found the requested Qulipta is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested medication is 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.
Appeal type: Medical Necessity
Decision: Overturned

A 60-year-old female enrollee has requested for a bilateral breast MRI performed for evaluation of her breast cancer. Findings:  The physician reviewer found that has a diagnosis of atypical ductal hyperplasia in the right breast and an MRI report raised the question of ductal carcinoma in situ, due to an abnormal area of enhancement next to a marking clip.  Since the subsequent excision was performed without MRI localization, it cannot be known if the suspicious area of enhancement was included in the surgical specimen.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 13-year-old female enrollee has requested chiropractic treatments (CLEAR) and a SpineCor brace for treatment of the enrollee's scoliosis. Findings:  The physician reviewer found that the efficacy and safety of the use of back bracing in patients with scoliosis has not been proven. In fact, the available medical literature indicates that back bracing can often worsen a patients spine. This patient presented with back pain as the primary complaint and was noted to have scoliosis. The chiropractic providers notes indicate that the provider was treating the patients back pain, and that the scoliosis was secondary. This patient responded well to the chiropractic treatment, with both a reduction in pain and spine curvature noted. The Mercy Guidelines justify chiropractic treatment for back pain that may be caused by a scoliosis curvature of the spine. Therefore, the chiropractic services at issue were and are medically necessary; however, the back brace at issue was not and is not medically necessary for treatment of this patients condition.
Appeal type: Medical Necessity
Decision: Upheld

The parent of an 11-year-old male has requested a comprehensive pediatric multidisciplinary assessment for treatment of his autistic disorder and mood disorder, not otherwise specified.   Findings:  The physician reviewer found that this patient has an extensive history of severe behavioral problems including verbalization of a desire to kill, suicide ideation, tantrums, and obsessive/compulsive actions. Intellectually, the patient is probably of superior intelligence and has above average fine motor skills. Based upon the documentation provided, the patient has already seen a child psychiatrist, a child neurologist, multiple educators and psychologists. A comprehensive pediatric multidisciplinary assessment would not be of significant clinical value at this time. The patients neurological exam has been normal, he is of superior intelligence, and has above average motor skills. His neurological tests include a normal video-monitoring electroencephalogram so further neurodiagnostic studies are likely to be of limited yield.  The paper by Rapin cited above, points out that a child neurologist should be judicious in evaluating developmental and behavioral issues and defer to child psychiatrists when the individuals problems are psychiatric in nature. In this case, the clinical utility of a comprehensive pediatric multidisciplinary assessment has not been established. As such, the requested service is not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 13-year-old male enrollee has requested residential treatment center care for treatment of the enrollees behavioral health condition.  Findings:  The physician reviewer found the residential treatment center services was medically necessary for treatment of the patients medical condition. This patient met continued stay criteria as he was still experiencing a great deal of turmoil in his life, given the recent allegations of sexual abuse and the ongoing CPS investigation. The patient also had a past history of quickly relapsing once he was released from the hospital, having already relapsed from his first inpatient treatment. Additionally, although he seemed to be doing well enough in the program to have earned his first pass, he immediately decompensated once released from the hospital. The social environment to which the patient was returning was characterized by stressors that would have likely undermined his treatment. Thus, there was a reasonable expectation that he would benefit from continued residential treatment center level of care. As such, the medical necessity of the disputed treatment has been established.
Appeal type: Medical Necessity
Decision: Upheld

A 56-year-old female enrollee requested authorization and coverage of continued acupuncture for the treatment of fibromyalgia.  The health plan denied the enrollees request indicating that the requested acupuncture is not medically necessary An acupuncture reviewer performed a medical necessity Independent Medical Review.  The acupuncture reviewer upheld the health plans denial on the basis that the requested acupuncture treatment is not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for the medication, Trulicity.Findings:  The physician reviewer found that there is support for the requested medication in this clinical setting. Trulicity is a member of  the glucagon-like peptide 1 (GLP-1) analogues, a new class of drugs used in the treatment of type 2 diabetes that mimic the endogenous hormone GLP-1.  This class of medications has shown significant improvements in glycemic control hemoglobin A1c reductions of 0.8-1% across studies, progressive weight loss, low incidence of hypoglycemia and potential improvement of cardiovascular risk factors.  Another important possible additional benefit of Trulicity relates to potential improvements in beta cell function. By initiating treatment with Trulicity relatively early in the course of diabetes, one may be able preserve beta cell function for the long term, halting or slowing down the progression of diabetes. In this patients case, he has not been able to optimize his glycemic control with Janumet and insulin.  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: Overturned

A 56-year-old female has requested approval for capsulectomy, scar tissue removal, and breast implant  for treatment of her right breast capsular contracture following bilateral breast augmentation, lumpectomy, and radiation therapy.   Findings:  The physician reviewer found that the submitted documentation demonstrates the medical necessity of the requested capsulectomy and scar tissue removal.  However, the requested breast implant replacement is not medically necessary in this patients case.  Surgery for visible but non-painful capsular contracture (grade III) is considered to be not medically necessary.  However, if there is painful symptomatic grade IV capsular contracture and/or rupture of a silicone gel implant, removal of the implant with capsulectomy would be considered medically necessary.  In this patients case, removal of the capsule and implant with or without placement of a new implant should alleviate the pain.  Thus, replacement of these implants, which were originally placed for cosmetic reasons, with new breast implants is not medically indicated.  All told, a portion of the requested services (capsulectomy and scar tissue removal) is medically indicated in this patients case.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a nerve block epidural.The submitted documentation supports that the requested nerve block epidural is medically necessary. Current evidence suggests that lumbosacral transforaminal epidural steroid injection (TFESI) is an effective treatment for lumbosacral radicular pain. In this case, the patient has low back and right sided radicular pain. She benefitted from a prior epidural steroid injection, and underwent a microdiscectomy at L4-5 with 50% relief for 6 months. Her provider has documented recurrent low back and radicular pain, and has administered epidural steroid injections at two levels with 40% relief. The provider has requested a third epidural steroid injection at L2-3 based upon the dermatomal distribution of pain. Under these circumstances, the requested nerve block epidural is supported by medical literature and appropriate to treat the patients low back and radicular pain. Therefore, the requested nerve block epidural is medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested service 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 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.