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

Findings:  The physician reviewer found that An enrollee has requested authorization and coverage for bilateral GelSyn Injections (J7326).Current medical literature pertaining to viscosupplementation reveals mixed results. Evidence from eight systematic reviews and six randomized controlled trials indicates that although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known which individuals will benefit. Different studies have tried mixing hyaluronic acid with corticosteroids, platelet rich plasma, and other agents to make it more effective. The current evidence is limited, and guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate that the evidence is not conclusive. As such, the academy does not currently support viscosupplementation as standard treatment for osteoarthritis of the knees. 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, there is a history of lasting excellent benefit from prior injections of GelSyn. Furthermore, other modalities such as physical therapy, home exercises, bracing, and cortisone injections have not been effective, with the only other alternative being total knee arthroplasties, which the patient wishes to avoid. Under these circumstances, the requested bilateral GelSyn Injections (J7326) are medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested services are medically necessary to treat the patients medical condition. Therefore, the Health Plans denials should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a 15-year-old female has requested coverage for acupuncture treatment for treatment of the enrollees shoulder pain. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue in this patients case.  This patient has not failed or exhausted conservative therapy for her shoulder pain.  Appropriate care for shoulder pain associated with mild tendinitis and bursitis is at least six to eight weeks of physical therapy, three months of anti-inflammatory medications, and rest from the exacerbating activity. The documentation does not demonstrate that the patient has failed these modalities.  Green and colleagues published a review on the varying interventions for shoulder disorders.  The authors concluded that there is evidence that some physiotherapy interventions are effective for specific shoulder disorders.  In this patients case, she may benefit from completion of conservative therapy.  All told, acupuncture treatment was not and is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

A 41-year-old female enrollee requested authorization and coverage of a referral to a center specializing in the treatment of cystic fibrosis for coordinated care. The Health Plan denied the request indicating that the requested referral is not medically necessary for treatment of the enrollees cystic fibrosis.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested referral is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested coverage for laparoscopic total hysterectomy for treatment of the enrollees uterine fibroids, ovarian cyst and pelvic pain syndrome.  Findings:  The physician reviewer found that Uterine fibroids are the most common solid pelvic tumors in women and the leading indication for hysterectomy. The two most common symptoms for which women seek treatment for this diagnosis are abnormal bleeding and pelvic pressure. Symptoms and treatment options are affected by the size, number, and location of the leiomyomas. Furthermore, acute pelvic pain is a common presenting complaint in women. The differential diagnosis includes gynecologic, urologic, musculoskeletal, gastrointestinal, vascular and metabolic disorders. A thorough history and physical examination is necessary to narrow the possible diagnoses and focus the work-up. In this case, it is likely that the patients pelvic pressure and potentially her back pain are caused by the location of her fibroid. However, it is not clear whether the acute onset of left lower quadrant pain can be explained by her fibroid uterus, especially in light of the fact that the uterus has markedly decreased in size in the last few years and this has been a longstanding diagnosis. Thus, the differential diagnosis of her complaints includes both urologic and gastrointestinal etiologies. These two etiologies have not yet been adequately addressed in the patients preoperative work-up. In addition, there is no documentation of an endometrial biopsy. Since the patients acute onset of left lower quadrant pain with no ovarian abnormality has not been adequately evaluated, the requested laparoscopic total hysterectomy is not supported as medically necessary. Final Result: The reviewer determined that the requested surgery 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 obstetrics and gynecology 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 an eight-year-old male enrollee has requested speech therapy for the treatment of the enrollees autism. Findings:  Three physician reviewers found that autism is a complex neurological disorder with characteristic deficits in speech/language and social interaction. There are likely a multitude of etiologies, with clinical symptoms being the common denominator. There is a long history of approaches used to intervene and facilitate development of adequate communication and interpersonal skills in this patient population. Typically, children on the autistic spectrum require interventions in multiple areas, provided using a team approach, consisting of several modalities including speech therapy. Fundamental to the diagnosis of autism spectrum disorder are deficits in speech and language. As noted by Volkmar, research has shown that early intervention focused on communication and social skills can significantly improve the outlook for individuals on the spectrum. Children with autism have deficits in speech and language, as well as social communication. Speech therapists are equipped to handle the myriad of communication challenges that face autistic patients. As such, speech and language therapy is medically indicated, and two hours per week is appropriate.
Appeal type: Medical Necessity
Decision: Upheld

A 44-year-old female enrollee requested psychiatric inpatient hospitalization for medical treatment of her bipolar disorder, depressed type.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services.  The documentation included a letter from the patients psychiatrist, an admitting note and a history and physical, in addition to notes from the emergency department.  However, records detailing the inpatient stay were lacking.  The documentation did not contain information such as a treatment plan, an interpretative summary, daily progress notes with mental status examination, serial suicide risk assessments or evidence of discharge planning efforts.  As such, there was no sequential description of the illness burden and its subsequent impairment, status update of the home environment, or review of past treatments tried and failed that would have justified treatment at the inpatient level of care.  Without said information, and considering the relevant peer-reviewed literature and current practice standards, the records do not demonstrate that the service improved the patients condition, prevented a more serious health condition or reduced morbidity.  All told, psychiatric inpatient was not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for acute inpatient rehabilitation care. Multidisciplinary rehabilitation plays a role in the management of pain associated with spine conditions and following spine surgery in general. General goals would include pain management and optimizing function towards independence. In the present case, the enrollee sustained her original injury and underwent multilevel vertebroplasties. She has had chronic back pains and limited mobility since that time. The patient sustained another injury and has been undergoing rehabilitation but has been making very slow progress. She and her family are requesting care at the acute inpatient rehabilitation level of care. A psychiatric consultation was obtained, which indicated that the patient was making very slow progress overall and opined that she was not a candidate for acute inpatient rehabilitation. Given the patients limited baseline functional status and the slow rate of progress with rehabilitation overall, the patient would not be expected to tolerate or marginally benefit from acute inpatient rehabilitation over rehabilitation provided in a less intensive setting.  Her principal rehabilitative issues are chronic in nature and her recovery is expected to be protracted. Acute inpatient rehabilitation at this time is not expected to favorably impact her clinical course or outcomes. Therefore, the requested acute inpatient rehabilitation care is not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in physical medicine and rehabilitation with sub-specialty certification in spinal cord injury 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 39-year-old female enrollee has requested for Solodyn for treatment of her cystic acne.  Findings:  The physician reviewer found that the patient does not provide any documentation of a trial of doxycycline, such as providing records from her prior physicians. If documentation were provided of a prior trial of doxycycline, then medical necessity from Solodyn would be established.
Appeal type: Experimental/Investigational
Decision: Overturned

A 30-year-old female enrollee has requested biofeedback for the treatment of her pelvic floor dysfunction. Findings:  Three physician reviewers found that this patient has tried other treatment options, but they have failed. The articles provided tend to show that biofeedback therapy is the superior treatment option for pelvic floor dysfunction. The only surgical treatment option for this patient is an iliocolostomy which would be a drastic measure without exhausting all other conservative treatment options.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 31-year-old male with generalized social phobia disorder. Based upon the information provided, it appears the patient does not wish to pursue pharmacotherapy. He has been receiving individualized psychotherapy since 2003. The patients provider indicates that although the patients symptoms have improved, he continues to require individualized psychotherapy. The Health Plan has determined additional psychotherapy is not medically necessary for treatment of the patients condition.Though it appears the patient has been making progress with psychotherapy, the acceptable and appropriate treatment for the patients social phobia also includes pharmacotherapy. The patient has declined pharmacologic treatment. The submitted evidence demonstrates the patient has already received 42 sessions of psychotherapy. There is no evidence the patient is experiencing acute adverse symptoms or comorbid medical problems. As such, there is insufficient evidence continued psychotherapy is medically indicated. Therefore, I have determined that the requested therapy is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the Prometheus Anser IFX diagnostic testing for evaluation of the enrollees ulcerative colitis. Findings:  The physician reviewer found that In this case, Prometheus Anser IFX diagnostic testing was ordered to determine Remicade level, and whether antibodies to Remicade were present. However, loss of response to Remicade can occur for many reasons. The presence of antibodies alone does not necessarily result in loss of response to infliximab or infusion reactions, nor have threshold levels been established. Studies have found that anti-infliximab antibodies can be transient, and disappear over time, with many patients who have these antibodies maintaining their response. A study concluded that prospective evaluation of the value of measuring serum concentrations of infliximab should be performed before these data can be included in patient management strategies. In summary, the medical literature lacks high-quality controlled studies to define drug level or antibody level thresholds requiring action to definitively establish that use of Prometheus Anser IFX improves outcome. The medical literature is not sufficient to establish improvement in health outcomes, and studies are contradictory. For these reasons, the Prometheus Anser IFX diagnostic testing performed was not likely to be more beneficial for evaluation of the patients ulcerative colitis than any available standard therapy. Final Result: The reviewers determined that the testing at issue was 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 reviewer number one is board certified in internal medicine with sub-specialty certification in gastroenterology 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.Physician reviewer number two is board certified in internal medicine with sub-specialty certification in gastroenterology 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.Physician reviewer number three is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 47-year-old male with knee pain who has undergone Hyalgan injections three times in the past five years. He wishes to undergo a forth series of injections. The Health Plan has denied authorization for the requested injections indicating they are not likely to be effective and therefore are not medically necessary.The use of Hyalgan and other hyaluronic products is common in the orthopedic community for treatment of joint pain. However, studies have not shown any benefit with multiple series of Hyalgan injections. The patient has already received three series of Hyalgan  a forth series is not medically indicated. Given that there are no long-term, prospective studies demonstrating the effectiveness of another series of Hyalgan in this clinical setting, I have determined the requested injections are not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Xyrem 500 mg/mL solution, 4.5 grams, oral two times daily. A diagnosis of narcolepsy requires polysomnogram findings of no obstructive sleep apnea. The study should include sufficient sleep of at least six hours during the night, followed by a multiple sleep latency test (MSLT) with sleep latency less than eight minutes and two naps associated with sleep onset rapid eye movement (REM) associated with excessive daytime sleepiness. The records provided for review do not document a thorough polysomnogram or cerebral spinal fluid (CSF) orexin-A (hypocretin) level test to support a diagnosis of narcolepsy. Xyrem is indicated to treat appropriately diagnosed narcolepsy patients who have failed first-line of treatment. All told, the requested Xyrem 500 mg/mL solution, 4.5 grams, oral two times daily is not medically necessary for 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 subspecialty certification in sleep 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: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for the prescription medication Depo-Estradiol. The North American Menopause Society (NAMS) notes that hormone therapy (HT) remains the most effective treatment for vasomotor symptoms and the genitourinary syndrome of menopause and has been shown to prevent bone loss and fracture. The authors further note that treatment should be individualized to identify the most appropriate HT type, dose, formulation, route of administration, and duration of use. While Depo-Estradiol is typically not considered a first line treatment, in this case, the patient has reported significant skin irritation with transdermal therapy and was unable to tolerate oral therapy due to gastrointestinal side effects. Given that the patient reports good symptom control without side effects using Depo-Estradiol, the requested medication is medically indicated. Therefore, prescription medication Depo-Estradiol 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 obstetrics and gynecology 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 57-year-old male enrollee has requested authorization and coverage for continued residential treatment. The Health Plan denied the request indicating that the requested level of care is not medically necessary for treatment of the enrollees chemical dependency.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plans denial on the basis that the requested services are medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: A male enrollee has requested authorization and coverage for 20.5 hours per week of one-on-one applied behavioral analysis (ABA) services for treatment of the enrollees autism spectrum disorder.  Findings:  The physician reviewer found that the requested 20.5 hours per week of one-on-one ABA services are medically necessary for this patient. Children and adolescents with autism spectrum disorder have a high rate of irritability and aggressive symptoms. Matson and colleagues note that because of the increased physical size of older children and longer history of these problems, treating these behaviors effectively is important. Psychological methods, particularly ABA therapy, and pharmacotherapy have been the most frequently addressed treatments for challenging behaviors associated with autism spectrum disorder in the peer-reviewed literature. Severe problem behaviors such as aggression, self-injury, and property destruction can result in injury, and that behavioral interventions can significantly reduce such behaviors. In this case, the patient displays behaviors that put him at risk, including pica and elopement. In addition, his physical aggression towards others and inappropriate behaviors in public put him at risk. As such, the request for 20.5 hours per week of one-on-one ABA services have been established as medically necessary for treatment of the patients medical condition. 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 pediatrics with sub-specialty certification in developmental-behavioral pediatrics 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.