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

The patient has requested authorization and coverage for paravertebral spine injection of the lumbar spine 1-3 dexamethasone sodium phosphate. Researchers concluded that the accuracy of diagnostic facet joint nerve blocks and the efficacy of therapeutic facet joint interventions are supported by high-quality evidence for appropriately selected patients after failure of conservative treatment. Researchers also concluded that based on the present assessment for the management of spinal facet joint pain, the evidence for long-term improvement is Level II for therapeutic facet joint nerve blocks in the cervical, thoracic, and lumbar spine. This patient presents with a history of chronic low back and left hip pain. She has been diagnosed with lumbar spondylosis without myelopathy or radiculopathy. A pain management report noted severe paraspinal spasms and tenderness from L2-S1 and no focal deficits. The provider reports that the patient has undergone multiple lumbar facet joint therapeutic injections. There are no pain management documenting a positive response to the lumbar facet joint therapeutic injections. In addition, there are no clinical findings consistent with facet joint mediated pain to support the requested therapy. There is a lack of details on the patients prior conservative treatment. Moreover, there are no clear clinical findings of facet joint mediated pain at three specific levels. The records do not include reports or discussions of imaging findings of facet pathology to support paravertebral facet joint injection of the lumbar spine. All told, the requested paravertebral spine injection of the lumbar spine 1-3 dexamethasone sodium phosphate is not medically necessary for treatment of the patients medical condition.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 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: Medical Necessity
Decision: Upheld

A 53-year-old female enrollee has requested acupuncture for treatment of her corneal neuralgia.  Findings:  The physician reviewer found that in the medical literature, Shin and colleagues evaluated the safety and efficacy of acupuncture for ocular symptoms in dry eye patients. The authors reported that acupuncture may have benefits on the mid-term outcomes related to dry eye syndrome compared with artificial tears. However, the authors noted that verum acupuncture did not result in better outcomes than sham acupuncture. Despite this patients reports of temporary improvement obtained with prior acupuncture care, the requested additional acupuncture for the patients corneal neuralgia is not supported as medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Otezla 28 day starter pack for treatment of the enrollees guttate psoriasis. Findings:  The physician reviewer found that there is sufficient support for the requested medication in this clinical setting.  This patient has tried and failed treatment with several topical steroid creams.  She is unwilling to take the known associated risks of malignancy and infection associated with injectable biologic agents.  Otezla is an oral U.S. Food and Drug Administration (FDA) approved medication for the treatment of psoriasis and psoriatic arthritis.  No clinical monitoring is necessary for patients using Otezla, as it has an excellent safety record and is not considered to be immunosuppressive.  The patient also complains of an aversion to injectable agents.  Given the associated risks of biologic therapy, Otezla is a medically appropriate treatment.  It is not reasonable to require a patient to submit to known risks of alternative therapy when FDA approved, safer treatments are available.  All told, Otezla 28 day starter pack is medically indicated 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 physician reviewer is board certified in dermatology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 16-year-old male enrollee has requested residential treatment center services for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found the submitted documentation establishes the medical necessity for the residential treatment center services. The patients recent assaultive behavior, impulsivity and lack of insight, coupled with the severity of his symptom complex, justified a conservative stay at the residential treatment center setting. This patient posed a risk to self and others, and likely would have required another readmission to the acute level of care. According to the medical records, the patient recently revealed significant drug use. He continued to have depressed and anxious feelings with episodic thoughts of suicide and the urge to jump from a staircase. He feared arguments with his father at home would result in physical altercation. The additional stay requested from the treatment facility was reasonably expected to improve the patients condition and prevent a more serious episode of illness while ensuring a successful transition to a less restrictive treatment setting. Additionally, a treatment course at the residential level of care is within community standards for a case of such complexity. Based upon the records provided, continued residential treatment was medically appropriate and indicated. As such, residential treatment center services were medically necessary for the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 46-year-old female enrollee has requested Botox injections 4 times per year for treatment of her chronic headaches.  Findings:  The physician reviewer found that Botox injections are not medically necessary for treatment of this patients chronic daily headaches because its effectiveness has not been proven or confirmed within the peer-reviewed literature for this diagnosis. Matthew and colleagues performed a randomized double-blinded, placebo controlled trial on Botox for the prophylactic treatment of chronic daily headaches. The trial resulted in patients having on average, approximately, seven more headache free days compared to baseline. The primary time point difference, however, for Botox when compared to placebo was not statistically significant. The treatment also met secondary efficacy outcome measures, including the percentage of patients experiencing a 50% or more decrease in the frequency of headache days. Botox treatment for chronic daily headaches seems promising and is well tolerated. However, Botox treatment efficacy for chronic daily headaches is not proven to be statistically significant in trials or peer reviewed literature. Similarly, Silberstein and colleagues studied the safety and efficacy of different concentration of Botox for prophylactic use in chronic tension type headaches. The outcome suggests that Botox was effective as more patients had a decrease in tension headache days when compared to placebo. The primary endpoint, however did not demonstrate a statistically significant difference between Botox and placebo. In a more recent study by Aurora and colleagues, the safety and efficacy of multiple treatments of Botox as prophylactic treatment of episodic migraine headaches was assessed. The researchers concluded that there were no statistically significant between-group differences in the mean change from baseline in the frequency of migraine episodes per 30-day period. Overall, Botox injections for episodic, chronic, tension-type headaches or migraines may provide improvements in symptoms. However, a statistically significant difference between treatment groups and placebo could not be obtained to prove that Botox is more beneficial than any available standard therapy for headaches. Further, there was no documentation by this patients treating provider of headache frequency being substantially reduced by the end of the initial trial. All told, the patients request for coverage for Botox injections four times per year has not been established as medically necessary in this clinical setting.
Appeal type: Experimental/Investigational
Decision: Overturned

A 53-year-old female enrollee requested treatment with the NovoTTF-100A system and resumption of treatment with NovoTTF-100A for medical treatment of her recurrent glioblastoma multiforme.  Findings:  Three physician reviewers found that glioblastoma multiforme is a high-grade tumor that is best treated with resection, radiation therapy, and chemotherapy.  This patient has exhausted these options.  The NovoTTF-100A device has been approved to deliver alternating electrical fields to treat recurrent glioblastoma multiforme.  There is sufficient support for the use of NovoTTF-100A for this patient who has exhausted standard treatment options.  Therefore, treatment with the NovoTTF-100A system and resumption of treatment with NovoTTF-100A was and is likely to be more effective than other treatment options.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for magnetic resonance imaging (CPT 73721). Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the services at issue. In this patients case, x-rays of the hip were not conclusively diagnostic. She did not have gross arthritic disease, avascular necrosis or an occult fracture.  In this setting, MRI is the most appropriate next step. In an extensive review of the various causes of hip pain in an active individual, studies concluded that MRI can assist in treatment decision making, as well as detecting different causes of the patients symptoms. It may be appropriate to delay MRI in a patient who has sudden onset of hip pain, as patients will often heal without any significant intervention other than rest and anti-inflammatory medications. However, in this patients case, she has had symptoms for at least six months and could not relate the symptoms to any traumatic event. It was medically appropriate to obtain an MRI in this setting. Therefore, MRI (CPT 73721) provided was medically necessary for the evaluation of this patient. Final Result: The reviewer 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: 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

The mother of an eight-year-old male enrollee requested authorization and coverage of sensory integration therapy for treatment of the enrollees medical condition. The Health Plan denied the request indicating that the requested therapy is not medically necessary for treatment of the enrollees autism. One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plans denial on the basis that six more months of the requested therapy is medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

A 27-year-old male enrollee has requested Supartz injections for the treatment of his bilateral patellofemoral pain. Findings:  The physician reviewer found that the records indicate that viscosupplementation has been used by this patient in the past with good results. Viscosupplementation is FDA approved for treatment of mild to moderate osteoarthritis. While the Health Plan is correct in that the patient is requesting an off-label use of viscosupplementation, these injections have been successful in the past for this particular patient. Given the documented benefits and low risk associated with this therapy, additional Supartz injections are medically appropriate and indicated for this patient.
Appeal type: Experimental/Investigational
Decision: Overturned

A male enrollee requested an anus exam (high resolution anoscopy) for medical evaluation of his high grade squamous intraepithelial dysplasia and HIV.  Findings:  Two physician reviewers found that high resolution anoscopy is used in high risk populations for surveillance and has been endorsed by the National Comprehensive Cancer Network (NCCN) in this clinical setting.  Thus, the anal exam (high resolution anoscopy) was likely to have been more beneficial for evaluation of his medical condition than any available standard testing.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patients parent has requested reimbursement and prospective authorization and coverage for intensive outpatient program (IOP) services. The American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists Child and Adolescent Level of Care Utilization System (CALOCUS) provides a reliable framework for determining the appropriate level of care for adolescents needing mental health treatment. Based on CALOCUS criteria, this patient meets the criteria for IOP treatment. The patient has been at significant risk of harm to others (score 3) as evidenced by the patients past suicidal ideation with plan, as well as episodic impulsivity and distress. The patient has demonstrated moderate functional impairment (score 3) given his difficulty connecting with peers, social isolation, absences from school, and gains made in the structured setting of the IOP. The patient has no significant comorbidities (score 1) due to the absence of medical illness. The patients recovery environment is moderately stressful (score 3) as evidenced by bullying by peers as well as the patients struggles to cope with school. The patients recovery environment provides limited support (score 3) due to his parents struggles to accept and respond to the patients autism spectrum diagnosis. The patient has shown poor resiliency and response to treatment (score 4) based on the patients continued symptoms even with prolonged treatment, and distress in response to developmental pressures. The patient has been constructive in treatment (score 2) as the patient has attempted to fully participate in the program. The patients parents have been obstructive with the patients treatment (score 3) as his parents are participating actively in program but struggling to accept and address the patients autism spectrum diagnosis. This gives the patient a composite score of 20, which meets the criteria for medically monitored community based services. This level of care can include IOP and home-based wraparound care. Houston and colleagues noted that the ideal treatment setting for adolescents is at home with their families. A child or adolescent with mental illness should be treated in the safest and least restrictive environment and needed services should be wrapped around to provide more intensive home or community-based services. Given these findings, the IOP services were and are medically necessary for treatment of this patient.Final Result: The reviewer determined that the services at issue were and 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 psychiatry with subspecialty 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: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested Actemra for the treatment of his medical condition.   Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication.  Bortezomib would be the next agent to attempt to eliminate donor specific antibodies.  Per the current medical evidence, there is a lack of support for Actemra in treating antibody mediated rejection.  The medical records do not support the requested medication in this clinical setting.  All told, Actemra 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 internal medicine with sub-specialty certification in nephrology 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 authorization and coverage for an epidural injection for treatment of the enrollees medical condition.  Findings:  The physician reviewers found that there is a lack of support for the requested services in this clinical setting.  There is a paucity of information published on the use of epidural steroids in the thoracic spine.  Further, the patient has compression of the thoracic spinal cord.  Administration of liquid into the thoracic epidural space may lead to further compression of the spinal cord.  The standard of care here is an open decompression procedure, not an epidural steroid injection which will increase pressure in the epidural space and may further compromise the spinal cord. Final Result: Two of three reviewers determined that the requested services 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 number one, two, and three are board certified in anesthesiology with sub-specialty certification in pain medicine 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

A 39-year-old female enrollee has requested Duodenal Switch surgery for the treatment of her morbid obesity. Findings:  The physician reviewer found that this patient meets the criteria for weight loss surgery as outlined by National Institutes of Health. She has a body mass index (BMI) of greater than 50. This places her at the super morbidly obese range. All of the referenced articles provided by the patient are clear that the Duodenal Switch operation is superior with regards to the percentage of excess body weight loss and sustained weight loss. Additionally, the Duodenal Switch is more efficacious when it comes to the potential resolution of the patients co-morbid conditions.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 52-year-old female with a history of low back and leg pain who has been diagnosed with grade I anterior spondylolisthesis at L5-S1.  She has tried conservative treatment with chiropractic therapy but does not wish to pursue any other conservative treatment modalities. The patients provider recommends lumbar fusion at L5-S1, which was denied by the Health Plan based upon a determination that the procedure is not medically necessary.The patient has not had a formal trial of physical therapy and therefore does not yet meet criteria for lumbar fusion surgery. She may be a candidate for surgery in the future if physical therapy does not resolve her problem, but conservative options should be exhausted before surgical intervention. Surgery for spondylolisthesis is generally effective in patients who have tried and failed physical therapy. Therefore, if the patient fails to obtain relief from a trial of physical therapy her request for lumbar fusion should be reconsidered. Based upon the information set forth above, I have determined the requested procedure is not medically necessary for treatment of the patients medical condition at this time. The Health Plans denial should be upheld at this time.
Appeal type: Medical Necessity
Decision: Upheld

A 38-year-old female enrollee has requested for an out-of-network referral for surgical services for treatment her arteriovenous malformation. Findings:  The physician reviewer found that review of the medical literature regarding treatment of AVM includes a study in which operative intervention was directed at primary resection in 15 cases, stage resection in 7 cases, embolization and resection in 5 cases, and evacuation of hematoma in 3 cases. Operative mortality in this surgical series was 7%, with significant morbidity in 13% of patients. Open surgery is associated with multiple potential complications including cerebellar mutism, paralysis and death. There is also a high likelihood of leaving residual AVM behind depending on the pattern of venous drainage. Use of modern microsurgical techniques in removal of posterior fossa AVMs may offer better results than the natural history of the disease process, especially in patients who present with hemorrhage. Radiosurgery is an acceptable treatment for patients with small AVMs in whom a higher obliteration rate can be achieved with lower risks of interval hemorrhage compared with the reported results in the general population. Careful follow-up observation is required, however, even after angiographically verified obliteration.