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

The patient is a 42-year-old man with a history of chronic neck pain and sleep disorder. The patients chronic neck pain secondary to degenerative disc disease status post laminectomy and fusion has been treated with pain medications including hydrocodone, Oxycontin, Methadone, and Percocet. The patient was subsequently weaned off all opiates. In October 2001, the patient was started on buprenorphine, which adequately managed his pain. The patient also had increasing symptoms of sleep disorder for which he was tried on benzodiazepines, Ambien, anti-epileptic drugs, tricyclics, chlorhydrate, phenobarbital, and antihistamines. However, the medications used either had significant side effects or did not have any effect on his sleep. The patient was started on Xyrem in August 2003, which improved the patients sleep disorder thus allowing him to be more functional. The patient has requested authorization for buprenorphine and Xyrem. The Health Plan has denied the request on the basis that the requested medications are not medically necessary.Review of the submitted clinical records demonstrates the patient has done well on his current regimen of medications--buprenorphine for chronic neck pain since October 2001 and Xyrem for sleep disorder since August 2003. He has failed numerous other treatments for chronic pain and sleep disorder. The patient continues to be followed by the provider who started him on buprenorphine and Xyrem. The evidence suggests the patient will continue to benefit on his current regimen as it allows him to be more functional. Therefore, continuation of treatment with buprenorphine and Xyrem is medically indicated. The patient should be closely followed by his provider since both medications are highly controlled substances. Based upon the information set forth above, I have determined that the requested medications are medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:The parent of a 10-year-old male enrollee has requested authorization and coverage for an echocardiogram for treatment of the enrollees chest pain. Findings:  The physician reviewer found that At issue in this case is whether the requested echocardiogram is medically necessary for treatment of the enrollees medical condition.Per Hussain and colleagues, chest pain is a reasonably common complaint in the pediatric population. In terms of referral to pediatric cardiology, it ranks second only to heart murmurs. The most common cause is idiopathic, occurring in up to half of cases. Other causes include pulmonary, musculoskeletal, gastrointestinal, and psychological. Actual cardiac causes are present in less than 5% of cases. Most children have normal physical exam findings. Interventions depend upon etiology: bronchodilators for reactive airways disease, anti-reflux medications for gastroesophageal reflux, and non-steroidal anti-inflammatory medications for musculoskeletal pain. When cardiac cause is suspected, a reasonable evaluation would include comprehensive history and complete physical examination, selective laboratory studies including metabolic studies and indicators of cardiac stress, electrocardiogram, chest x-ray, and echocardiogram. In some cases, a period of cardiac monitoring may be indicated. Other patients may benefit from a Holter 24-hour monitor or an event monitor. In this patients case, he initially presented with chest pain that began during physical education class, and with subsequent onset of dry cough. He was evaluated multiple times by all pertinent specialists, with normal testing throughout and examination consistent with costochondritis. Ultimately he was also diagnosed with habit cough after completing a course of prednisone and azithromycin. There is nothing in his history or the submitted documentation that would indicate that an echocardiogram would add any additional useful information. Therefore, the echocardiogram is not medically necessary. Final Result: The reviewer determined that the requested service 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 pediatrics with subspecialty certification in pediatric critical care 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 38-year-old male enrollee requested authorization and coverage of chiropractic treatment. The Health Plan denied the request indicating that the requested treatment is not medically necessary for treatment of the enrollees pain.One chiropractic reviewer performed a medical necessity Independent Medical Review. The chiropractic reviewer upheld the Health Plans denial on the basis that the requested therapy is not medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Xeomin for treatment of the enrollees piriformis syndrome and right lower leg pain. Findings:  Three physician reviewers found that IncobotulinumtoxinA (Xeomin) and onabotulinumtoxinA (Botox) are approved by the U.S. Food and Drug Administration (FDA) for the treatment of adults with cervical dystonia or blepharospasm. However, there is a lack of peer-reviewed clinical trials and evidence that Xeomin may be useful in the treatment of piriformis syndrome. One study noted that treatments for piriformis syndrome include physiotherapy, steroid injections, and surgery. All told, the requested Xeomin 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. Credentials/Qualifications:  The physician reviewers 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: Upheld

A 58-year-old female enrollee requests for a repeat DEXA scan for evaluation of her osteopenia.  Findings:  The physician reviewer found that a follow-up DEXA scan is not indicated within one year of the initial test unless specific conditions are met. As such, a repeat DEXA scan is not necessarily at this time. A follow-up DEXA scan two years after the initial test would be appropriate to monitor the patients condition.
Appeal type: Medical Necessity
Decision: Upheld

The enrollee is requesting reimbursement for intensity modulated radiation therapy (IMRT). The enrollee has stage 4 rectal cancer. The enrollee had received chemotherapy and was doing well.  His physical exam did not reveal any significant abnormalities.  The physician recommended an evaluation for intensity modulated radiation therapy concurrent with chemotherapy, because it was necessary to increase the dose to the cancer while reducing the dosage to closely adjacent vital organs.  Literature demonstrated the use of intensity modulated radiation therapy with chemotherapy in the management of rectal carcinoma is associated with a clinically significant reduction in gastrointestinal toxicity when compared with three-dimensional conformal radiation therapy. Professional society guidelines indicate that, for rectal cancer, the use of intensity modulated radiation therapy should be limited to a clinical trial or other unique clinical situation. The records do not indicate intensity modulated radiation therapy is superior and must be used over three-dimensional planning.Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in radiation oncology 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

Findings:  The physician reviewer found that the patient has requested authorization and coverage for Tepezza (J3241). This patients records document a history of thyroid eye disease causing proptosis and eyelid retraction. The patients condition has failed to improve despite treatment with selenium, artificial tears, gel, and Restasis. The patients provider has recommended treatment with Tepezza. Thyroid eye disease is an autoimmune disorder that is associated with hyperthyroidism and can cause orbital disfigurement, double vision, and loss of vision. Management is guided by disease activity and severity status. Previously, treatment options were limited to the control of hyperthyroidism, local eye measures, glucocorticoids, selenium, orbital radiotherapy, and surgery (Kotwal and Stan). Newer targeted biologic therapies have shown promise, including Tepezza, which is an IGF-1 receptor antagonist. On review of the available clinical data, Tepezza has been demonstrated to substantially reduce proptosis associated with Graves ophthalmopathy (Kahaly, et al.). In addition, Tepezza has been shown to help reduce disease activity and the severity of Graves ophthalmopathy (Genere and Stan). For these reasons, the requested Tepezza (J3241) 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 internal medicine with subspecialty certification in diabetes, endocrinology, and metabolism and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for five Supartz injections 10mg/ml. The Health Plan has denied this request indicating that the requested injections are not medically necessary for treatment of the enrollees bilateral knee osteoarthritis.At issue in this case is whether the requested five Supartz injections 10mg/ml are medically necessary for treatment of the patients medical condition.Researchers concluded that hyaluronic acid was the best pharmacologic intervention for knee osteoarthritis. Hyaluronic acid was found to be better than injected placebo or injected corticosteroids. A study conducted a systematic review of overlapping meta-analyses comparing intra-articular hyaluronic acid with other non-operative treatment modalities for knee osteoarthritis. They reported that the current highest level of evidence suggests that intra-articular hyaluronic acid is a viable option for knee osteoarthritis. Researchers concluded that repeated cycles of intra-articular sodium hyaluronate treatment to delay time to total knee replacement in patients with knee osteoarthritis, which failed conservative treatment, was found efficacious during a 54-month follow-up period. The American Medical Society for Sports Medicine recommends hyaluronan acid for appropriate knee osteoarthritis patients, based on a very large network meta-analysis. Evidence based medical peer-reviewed literature supports the use of vicsosupplementation injections for the treatment of pain in patients with osteoarthritis of the knee. Vicsosupplementation has been found to be safe and effective and allow for delay of total knee replacement, and is more effective than corticosteroid injections.In this case, the patient presents with bilateral knee pain and has been diagnosed with bilateral knee osteoarthritis. Painful bilateral knee range of motion and crepitus is documented. He has failed to respond to conservative treatment with intra-articular steroid injections and prescribed non-steroidal anti-inflammatory drugs. Prior Supartz injections on three occasions have provided total elimination of pain and functional restoration in knee motion. Therefore, the requested Supartz injections for the bilateral knees are medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the requested injections 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: Medical Necessity
Decision: Upheld

A 44-year-old male enrollee has requested for long-term acute care for treatment of his herpes simplex 1 viral encephalitis. Findings:  The physician reviewer found that patient was medically stable, and he was able to go up and down stairs (20 steps) with the use of handrail. The patient was naming tasks with 55% accuracy, and he followed written directions with 100% accuracy.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient requested authorization and coverage for home infusions of Gammagard (human intravenous immune globulin) 40 grams every two (2) weeks. According to the practice parameters from the American Academy of Allergy, Asthma and Immunology and the American College of Allergy, Asthma and Immunology, this patients presentation is consistent with a primary antibody deficiency. The patient has evidence of hypogammaglobulinemia as well as recurrent sinusitis and pneumonia. The patients baseline total IgM and IgG are low and laboratory studies revealed low titers to polysaccharides. She has had other conditions which have required treatment that is known to deplete B-cells. In addition, the records document a failed response to a pneumonia vaccine. Given this patients hypogammaglobulinemia, low IgM, low B-cell numbers, and poor polysaccharide response, the patient meets the criteria for common variable immune deficiency (CVID). The medical literature supports a role for IVIG in this clinical setting. This patient continues to have infections despite monthly IVIG infusions at home. The guidelines support an increase in the IVIG interval to every two weeks to determine if there is a reduction in the frequency of infections. As noted by the provider, infusions at home will also help prevent the risk of the patient developing recurring infections involving the lung, which improved with IVIG at home. Therefore, the home infusions of Gammagard (human intravenous immune globulin) 40 grams every two (2) weeks are medically necessary for treatment of this patients CVID. 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 internal medicine with subspecialty certifications in allergy and immunology and rheumatology 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 six-year-old male enrollee has requested for speech therapy for treatment of his speech and language delays. Findings:  The physician reviewer found that speech and language delay must be taken very seriously in young children, as the long-term consequences may be substantial. In this particular childs case, entry into elementary school has been delayed because of his speech and language difficulties. According to a Cochrane Database meta-analysis of 25 studies, approximately 6% of children have speech and language difficulties. Whilst most childrens difficulties resolve, children whose difficulties persist into primary school may have long-term problems concerning literacy, socialization, behavior and school attainment. These reviewers conclude that this meta-analysis shows overall there is a positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulties.
Appeal type: Urgent Care
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested hospital services on an emergent 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 was involved in a high speed automobile accident. While the patients signs and symptoms were not severe, there was the potential for life threatening injuries sustained in the traumatic event. Therefore, a prudent layperson would have sought medical attention on the date of service in question because the absence of immediate medical attention could reasonably be expected to result in placing the patients health in serious jeopardy. All told, the patients symptoms would lead a prudent layperson to believe their health to be in imminent danger. In sum, the patients symptoms met 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: Medical Necessity
Decision: Upheld

A 44-year-old female enrollee requested authorization and coverage of two pair of compression stockings for treatment of varicose veins.  The health plan denied the enrollees request indicating that the requested stockings are 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 compression stockings are not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 15-year-old female enrollee has requested a registered dietician who specializes in treating anorexia patients for treatment of the enrollees eating disorder.  Findings:  The physician reviewer found that as noted in the American Psychiatric Association (APA) guidelines for eating disorders, Registered dieticians with specialized training in eating disorders often provide nutritional counseling. The APA guidelines further state that, For children and adolescents, the recommended treatment model is the team approach. In this interdisciplinary management approach, general medical care clinicians (e.g., specialists in internal medicine, pediatrics, adolescent medicine, or nutrition) manage general medical issues, such as nutrition, weight gain, exercise, and eating patterns, whereas the psychiatrist addresses the psychiatric issues. Thus, the APA criteria are clear that the nutritional advisor must be a person with individualized training in this area. As such, it would be insufficient, according to the guidelines, to have a psychologist undertake this role. Consistent with these recommendations, the request for a dietician with special expertise in adolescent eating disorders is medically necessary in managing this patients eating disorder according to the APA guidelines.
Appeal type: Experimental/Investigational
Decision: Upheld

A 34-year-old female enrollee has requested biofeedback therapy for treatment of her urinary incontinence.  Findings:  Three physician reviewers found that biofeedback for incontinence has been studied extensively. Review of the relevant scientific literature fails to show additional benefit or sustained benefit over that obtained with pelvic floor exercises alone. As such, there is inadequate data to warrant the use of biofeedback as an adjuvant to standard therapy.
Appeal type: Experimental/Investigational
Decision: Overturned

The parent of a ten-year-old male enrollee has requested for occupational therapy for treatment of the enrollees autism.   Findings:  Two physician reviewers found that current recommendations at most major medical centers support the use of occupational therapy as a useful aid in the overall treatment of autism spectrum disorders. There is sufficient data to support occupational therapy is necessary and more beneficial than any other modality of treatment.