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

Nature of Statutory Criteria/Case Summary:  An enrollee has requested incision for implantation of cranial nerve (eg. vagus nerve) neurostimulator electrode array and pulse generator for treatment of his obstructive sleep apnea. Two physician reviewers found that the requested services are not likely to be more effective for this patient than other available options. The standard of care for the treatment of clinically significant OSA is CPAP, which has been documented to be effective treatment for this patient and has been tolerated in the sleep center. The vast majority of patients with OSA have significant obesity frequently bordering on morbid obesity. This patient is not obese. Patients who have OSA and are not obese frequently have positional sleep apnea that can be effectively treated with a vest containing a tennis ball to avoid supine sleep. On the basis of the reports from the sleep studies provided, positional sleep apnea has not be ruled out and there is no indication for the requested surgical procedure to implant an electrode and generator for vagus nerve stimulation until positional sleep apnea has been ruled out. Therefore, the request for incision for implantation of cranial nerve (eg. vagus nerve) neurostimulator electrode array and pulse generator is not likely to be more beneficial than standard medical therapy in this clinical setting. Final Result:  Two 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: One reviewer is board certified in neurology with sub-specialty certification in sleep medicine and is actively practicing.  Two reviewers are board certified in internal medicine with sub-specialty certification in pulmonary disease 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 22-year-old female enrollee has requested psychiatric residential treatment services for the treatment of her behavioral health problems. Findings:  The physician reviewer found that the description of the patient reveals evidence of manic or hypomanic behavior considering her history of pressured speech, tangentiality and inappropriate affect at the time of this admission. The patient presented with substantial paranoia and anxiety, in addition to an unkempt appearance. After three weeks into the admission at issue, the patient was still manifesting paranoia and racing thoughts and coping with akathisia. The patient was having her medications actively titrated and she was discharged from this admission directly to another facility. This patient was an appropriate candidate for a residential level of care given her manic symptoms, paranoia, and long-standing substance use and dependence.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 52-year-old male with a history of hypertension and asthma. He underwent spinal fusion surgery two weeks prior to hospital admission. He presented to the emergency room in October 2005 with shortness of breath and bilateral lower extremity swelling. His admission diagnosis was respiratory failure due to pneumonia/CHF. He was evaluated by pulmonology and started on intravenous antibiotics, intravenous steroids, oxygen, and regular nebulizer treatments. His chest x-ray demonstrated evidence of a density involving the posterior aspect of the right upper lobe and an infiltrate at the right base. A chest CT scan demonstrated no evidence of pulmonary emboli with evidence of diffuse interstitial fibrosis and air space consolidation involving the posterior segment of the right upper lobe, areas of pleural thickening of the left base, focal density on the left lower lobe, speculated density on the right and left upper lobes, and another nodule density in the lower lobe. An echocardiogram revealed normal LV function with mild pulmonary hypertension. His diagnoses were pneumonia/bronchospasm/diffuse idiopathic interstitial pneumonitis.  The patient has requested reimbursement for his continued hospitalization from October 2005 through October 2005. The Health Plan had denied this request indicating that the services at issue were not medically necessary.Review of the submitted medical documentation indicates that as of October 2005 the patient was medically stable. He was afebrile with an oxygen saturation of 98%. He was switched from IV medications to oral prednisone and oral antibiotics (Levaquin). He had complaints of weakness and constipation, but received no therapy that required inpatient hospital services. The additional two days of hospitalization were not clinically indicated, as the patient was stable for discharge by October 2005. Therefore, I have determined the services at issue were not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 17-year-old female enrollee has requested residential treatment center (RTC) level of care services for treatment of the enrollees multiple mental health conditions.   Findings:  The physician reviewer found that this patient presented with escalation of self destructive and dangerous behaviors that were not contained in an outpatient setting while residing in her home. She was impulsive and showed very poor judgment that would not be expected to be improved with an outpatient level of care. The patient had been in psychiatric treatment for a prolonged period of time prior to the admission at issue and the start of her more serious acting out behaviors seemed to be correlated with external stimuli and changes in her home environment. She required pharmacotherapy stabilization during the said date, behavioral stabilization, and finally family stabilization, and was evidenced by a successful 30-hour pass with her family. All told, by the date in question, the patient could have transitioned home while being treated in a partial hospitalization program (PHP), with continued behavioral stabilization in the home setting, in preparation for more independent living.
Appeal type: Experimental/Investigational
Decision: Upheld

A 63-year-old female enrollee has requested the LINX reflux management system for treatment of her gastroesophageal reflux disease. Findings:  Two physician reviewers found that in this patients case, the requested services are not likely to be superior over other available treatment options.  There is a lack of support for the requested services in this clinical setting.  The data regarding the LINX procedure remains premature.  A randomized controlled trial with fundoplication as the comparator arm is needed in order to support the superior efficacy of the LINX procedure over standard treatment.  Therefore, the requested LINX reflux management system is not likely to be of greater benefit than other treatment modalities.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for ketamine infusion. Findings:  Three physician reviewers found that the submitted documentation fails to demonstrate the superior efficacy of the requested services. There were no medical records/progress notes from the provider, nor were there any individual psychotherapy notes. There was no record of the duration of each of the antidepressants listed, dosages, or any combinations that might have been used.  Furthermore, it is not known if dose optimization occurred in any of the medications tried.  There is no discussion in records provided, and no conclusion can be drawn, that the patient suffers from treatment-resistant depression.  If that were in fact the case, and all the above medication scenarios had occurred, the next step would be a discussion of electroconvulsive therapy, which remains a highly effective treatment for patients with treatment-refractory depression. Thus, the requested ketamine infusion is not likely to be of greater benefit than other available treatment options. Final Result: 3 of 3 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: All three physician reviewers 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 nasal scar revision. There is sufficient support for the requested services in this clinical setting. Photographs support the clinical documentation of significant scarring of the nose. However, no functional impairment has been associated with the external scar. Therefore, scar revision is not medically necessary at this point based on a functional consideration. However, the patients condition constitutes an abnormal structure of the body. Scarring an abnormal condition of the body. This abnormal structure is caused by acne, which is a disease. There is no evidence of functional impairment, but the procedure would be performed to help create a more normal appearance. Based on the records, the requested surgery would offer more than a minimal improvement in the appearance of the enrollee. Therefore, the requested nasal scar revision is reconstructive in nature. Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition but are reconstructive in nature. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in plastic 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 28-year-old female enrollee has requested for inpatient chemical dependency treatment for treatment of her alcohol and cocaine dependencies.  Findings:  The physician reviewer found that the patient clearly needed treatment, services could have safely and effectively been provided at a less intensive level of care.
Appeal type: Medical Necessity
Decision: Upheld

A 54-year-old female enrollee has requested authorization and coverage for the prescription medication Provigil for treatment of her attention-deficit disorder (ADD).  Findings:  The physician reviewer found that the specific ADD symptoms for which Provigil was felt to be helpful are not clearly differentiated from symptoms secondary to depression. Additionally, the trials of conventional ADD/ADHD medications do not appear to have been adequate in time or dosage. Provigil is not FDA approved for the treatment of ADD. It does not appear the patient has exhausted standard treatment options
Appeal type: Medical Necessity
Decision: Upheld

The parent of a 10-year-old male enrollee has requested speech therapy services for the treatment of the enrollees speech delay. Findings:  The physician reviewer found that the submitted clinical evidence does not demonstrate speech therapy was or is medically necessary for this patient. No evidence has been presented demonstrating that the etiology of the patients problem related to illness, injury or chronic disease. There is no documentation of a hearing evaluation, tympanometry, or clinical documentation supporting a diagnosis of chronic otitis media with effusion or hearing loss. Furthermore, the speech therapist found no abnormalities on the patients oral peripheral exam. Additionally, it appears the patient had an in-school speech and language evaluation, which concluded that his speech errors were very minor. Finally, there is insufficient objective evidence that the patient benefited from the speech therapy services he received.
Appeal type: Experimental/Investigational
Decision: Upheld

A 51-year-old female requested authorization and coverage of enhanced external counterpulsation (EECP) for the treatment of myocardial ischemia.  The health plan denied the enrollees request indicating that the requested treatment is considered experimental.Three physician reviewers performed an experimental/investigational Independent Medical Review.  All three-physician reviewers concluded that the requested EECP is not likely to be more beneficial for treatment of the enrollees myocardial ischemia than any available standard therapy.  Because all three-physician reviewers concluded that the requested treatment is not likely to be more beneficial for treatment of the enrollees medical condition than any available standard therapy, the review organization upheld the health plans denial.
Appeal type: Medical Necessity
Decision: Upheld

Findings:  The physician reviewer found that The patient has requested authorization and coverage for acupuncture services. Urits and colleagues state, Many studies have been done, and most show promising results for acupuncture as an alternative treatment for low back pain. Following an acupuncture trial of five or six sessions, additional acupuncture treatments should only occur based on progressively greater, incremental objective gains. Acupuncture should be combined with active care, such as conditioning, aerobics, and/or a stretching exercise program. Indications for care discontinuation include resolution, intolerance, lack of measurable improvements, or non-compliance including non-compliance with aerobic and strengthening exercises. In this case, while the patient reported benefits from prior acupuncture, the records did not document pre-acupuncture and post-acupuncture baselines for comparison purposes, and measurable, progressive, significant, or objective functional improvement. The documentation did not demonstrate a flare-up or extraordinary circumstances to be addressed in additional sessions and did not include a physical examination with clinical findings including the motor, sensory, and functional deficits to be addressed by the requested care. The records did not document that the patient was undergoing an independent exercise program. Given that measurable, progressive, significant, objective functional improvement has not been documented, the requested services are not medically indicated. Therefore, acupuncture services are 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.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Norco. At issue is whether the requested Norco is medically necessary for treatment of this patient. The Centers for Disease Control and Prevention (CDC) guidelines state that when opioid therapy is used, a patients regimen should include nonpharmacologic therapy and nonopioid pharmacologic interventions. Additionally, the CDC noted that, Clinicians should continue opioid therapy only if there is clinically meaningful improvement in pain and function that outweighs risks to patient safety. The Federation of State Medical Boards (FSMB) guidelines noted that, continuation, modification or termination of opioid therapy for pain is contingent on the clinicians evaluation of (1) evidence of the patients progress toward treatment objectives and (2) the absence of substantial risks or adverse events, such as signs of substance use disorder and/or diversion. The FSMB opined that dosage should be maintained as low as possible and continue[d] only if clear and objective outcomes are being met. In this case, the patient has chronic abdominal pain secondary to alcoholic cirrhosis. The records document that this patients provider has recommended cessation of alcohol consumption. The patient was referred to physical therapy, but the records indicate that she missed her appointments. The patient was also referred to pain management, but there are no reports from pain management in the available information. Furthermore, the patients providers have not recommended opioid therapy with Norco due to the unfavorable risk-to-benefit ratio. The patients providers have recommended non-pharmacological treatment modalities, which is consistent with current recommendations from the CDC and FSMB guidelines. Based on these findings, the requested Norco 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 anesthesiology with subspecialty 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

A 61-year-old female enrollee has requested an epidural injection for treatment of her pain. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  The peer-reviewed medical literature does not support the requested epidural injection in this clinical setting.  It was noted that the patient was referred to physical therapy.  However, the medical records lack documentation of the patients attempt at physical therapy and her response.  Abdi and colleagues found that there was moderate evidence for interlaminar epidurals in the cervical spine and limited evidence in the lumbar spine for long-term relief.  According to the medical records, the patient had multiple epidural steroid injections with variable results.  Per the clinical notes, the patients response to prior epidural steroid injections was not demonstrated by an increase in activity or reduction in pain medication.  All told, the requested epidural injection is not medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

A 31-year-old male enrollee has requested an NDO plication procedure, upper gastrointestinal endoscopy,laparoscopic hernia repair, laparoscopic fundoplasty, and surgical diaphragm repair) for treatment of his gastroesophageal reflux disease (GERD).  Findings:  Three physicicians found that endoluminal therapy has not been sufficiently studied, and is not yet considered a substitute for the traditional fundoplication procedures for the management of GERD. Long-term study results are lacking as are studies comparing these new endoluminal anti-reflux therapies with established treatments such as the Nissen fundoplication.  Although this approach is rapidly evolving and has generated a significant amount of interest within the GI community, endoscopic gastroplication procedures such as the NDO plication must be considered experimental/investigational at the present time.
Appeal type: Medical Necessity
Decision: Upheld

A 32-year-old female enrollee has requested bilateral inferior turbinate reduction for the treatment of her nasal airway obstruction. Findings:  The physician reviewer found that this patient was noted to have some difficulty breathing only when she has allergies which occurred primarily in the spring and summer months, and she was noted to have bilateral mild inferior turbinate hypertrophy.  Standard of care in determining whether a patient would benefit from surgical management of nasal congestion dictates that there be physical findings resulting in significant obstruction, i.e., prominent septal deviation, obstructive turbinate hyperplasia or nasal valve collapse.  In addition, failure of an adequate trial of medical therapy should be documented. Neither of these two elements are documented in this patients records. As such, medical necessity has not been established.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Zepatier 50-100 mg tablets for 12 weeks for treatment of the enrollees hepatitis C virus. Findings:  The physician reviewer found that according to the joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. This recommendation applies to all patients, regardless of fibrosis stage. The guidelines recommend that treatment naive genotype 1b patients should be treated with regimens including or Zepatier for 12 weeks, based on clinical trial results showing a 99% cure rate regardless of NS5A resistance. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. 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 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.