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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for magnetic resonance (MR) neurography for evaluation of the enrollees brachial plexus injury. Findings:  Two physician reviewers found that MR neurography has become valuable in the evaluation of such entities as sciatica, pudendal nerves, or thoracic outlet syndromes including brachial plexus injuries. One study states that MR neurography is a useful technique in evaluating patients with brachial plexus lesions, particularly in cases of brachial plexitis, where conventional magnetic resonance imaging is generally normal. According to another study, MR neurography can consistently report [the] accurate determination and localization of symptomatic nerve entrapment. In this case, there is some question concerning the etiology of his symptoms. His current symptoms may be musculoskeletal in nature. For this patient, MR neurography is clinically indicated in identifying the specific site of the patients nerve injury. Thus, MR neurography is likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: The reviewers determined that the requested diagnostic procedure is likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: All three physician reviewers are board certified in diagnostic radiology 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the digital breast tomosynthesis performed for evaluation of the enrollees breast cancer evaluation. Findings:  Three physician reviewers found that Tomosynthesis is a technique that was developed as a problem solving adjunct to routine mammography. In this case, the patient has breasts that have been described as being heterogeneously dense. While one could make the argument that her mammogram has not changed since the last study, it is specifically those patients who have dense breasts that can benefit most from tomosynthesis. The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor. Accordingly, the digital breast tomosynthesis performed was to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: All three physician reviewers are board certified in diagnostic radiology 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 55-year-old male has requested an increase in his dose of Oxycodone for treatment of his back and shoulder pain.   Findings:  The physician reviewer found that based on review of the available records, a dosage increase in Oxycodone for the patients right shoulder and back pain is not medically necessary. The patient has a chronic non-life threatening condition. The current standard of care for chronic pain is treatment in a multidisciplinary practice to include physical therapy, massage therapy, behavioral therapy, and injections to help reduce pain. Opiates are considered adjunctive to this therapy and use of controlled release narcotics with close monitoring by a certified physician is recommended. Short-release and short-acting medications with a high risk of dependence and tolerance, such as Oxycodone, are not recommended (Fishman). Baron and colleagues reported that high dose opiates might contribute to pain sensitization via opioid-induced hyperalgesia, decreasing patient pain threshold and potentially masking resolution of a preexisting pain condition. In this retrospective study, the majority of patients undergoing detoxification of high dose opiates for chronic pain reported a significant decrease in pain at the end of the study, further supporting the theory of opioid induced hyperalgesia. It is therefore in the patients best interest to wean off opioids and receive adjunctive therapy including non-narcotic medications, physical therapy, massage therapy, or cognitive behavioral therapy, in order to address his chronic pain. High dose opiates may also cause adverse outcomes. Ballantyne and colleagues reported that prolonged use of high dose opiates might induce tolerance, abnormal pain sensitivity, and hormonal effects. The aim of current guidelines is to protect patients from the adverse effects of opioid therapy.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a two-year-old male enrollee has requested speech therapy for treatment of the enrollees speech delay.  Findings:  The physician reviewer found that this patient has an identified delay in expressive and receptive speech of approximately 25-50% per the Rossetti Infant-Toddler Scale and Developmental Assessment of Young Children (DAYC). According to Law and colleagues, speech therapy is indicated with any delay greater than 25%. An extensive review of the literature including the meta-analysis by Law, et al. noted the positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulty. Feldman and Messick note that treatment for language disorders is predicated primarily on the patients language profile and level of communication skills. Approximately 50% of children delayed at two years catch up to peers by three years of age. Those children with mild to moderate disorders are more likely to resolve their delay compared to those with severe disorders. Children who participate in speech-language treatment show better improvement than those children who have no treatment. Children in bilingual households show language mixing in the early phases of language development but are able to segregate the languages into two separate systems as they acquire more language skills. Their development rate is not delayed if the accomplishments of the two languages are added together (Feldman and Messick). This patient has continued to display expressive and receptive language impairment with decreased acquisition of language skills. Therefore, speech therapy is medically necessary for this patient.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a five-month-old male enrollee requested in-home skilled nursing care and registered nurse (RN) care for medical treatment of the enrollees medical condition.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services.  This patient has undergone repair of congenital heart disease, gastrostomy tube placement, and Nissen fundoplication for gastroesophageal reflux disease.  He currently is fed by mouth, using the gastrostomy tube for medication administration.  The patient is hemodynamically stable, without oxygen requirement.  He has no respiratory issues and requires no breathing treatments.  The family was taught gastrostomy tube care and management prior to discharge home.  The medical records do not document that the patient requires the requested in-home skilled nursing care.  All told, the requested in-home skilled nursing care and  registered nurse (RN) care is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

A 63-year-old female enrollee has requested for EpiCeram Skin Barrier Emulsion for treatment of her atopic dermatitis/eczema. Findings:  The physician reviewer found that the use of EpiCeram in this patient is justifiable for the following reasons: she has moderate to severe atopic dermatitis (see Elias and Schmuth); her disease did not respond to the over-the-counter formulation (CeraVe); she has tried two topical corticosteroids of different groups, mometasone and triamcinolone (see Sugarman and Parish); and EpiCeram has been safely and successfully used to treat atopic dermatitis.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Xeljanz tablets. Findings:  The physician reviewer found that the submitted documentation supports that the requested medication is medically necessary. The use of Xeljanz for ulcerative colitis is well supported. Xeljanz has a different mechanism of action than anti-TNF therapies. In this case, the patient has failed alternatives, including the anti-tumor necrosis factor (TNF) medication Humira. The patient has started Xeljanz with good relief of symptoms. For this patient, the discontinuation of Xeljanz or a change to an alternate therapy may result in a disease flare or other complication. Under these circumstances, Xeljanz tablets are medically necessary for treatment of the patients medical condition.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 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: Urgent Care
Decision: Overturned

A 57-year-old male enrollee has requested for emergency services for treatment of his leg pain.  Findings:  The physician reviewer found that the patients symptoms met prudent layperson criteria for emergency care. A prudent layperson with an average knowledge of medicine and a history of diabetes, hypertension and high cholesterol and posterior leg pain that was acutely worsening after three days, would reasonably expect the absence of emergency care to jeopardize their health. DVT was high on the list of possible causes for the patients symptoms and physical exam findings. Patients with DVT are in immediate jeopardy of pulmonary embolism and a prompt diagnosis is paramount.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 66-year-old male and has neuropathic symptoms of painful foot and leg tingling. Spinal stenosis has been diagnosed. Lumbar laminectomy has been performed in the past. The patients HbA1C was normal, but fasting glucose was elevated. No glucose tolerance test results are cited. A podiatry evaluation for plantar fasciitis resulted in a diagnosis of neuropathic symptoms apparently from the back. NSAIDs, Neurontin, physical therapy, and spinal injections were tried without sustained relief. Recently, the patient received a trial of Lyrica. The patient and his provider indicate Lyrica has completely controlled his symptoms. At issue is whether Lyrica is medically necessary for treatment of the patients medical condition.The patient has symptoms suggesting polyneuropathy. Etiologic diagnosis is unclear. An elevated fasting blood sugar may indicate abnormal glucose tolerance, a risk for both diabetes mellitus and polyneuropathy, despite normal HbA1C. Based on the records provided, it does not appear the diagnosis of neuropathic symptoms from spinal stenosis has been confirmed by neurologic assessment. Treatment with Neurontin has been ineffective. The patient reports he has tried Lyrica with good relief.Response to treatment of pain from diabetic neuropathy often predicts response of pain from other sorts of painful neuropathy, which may not be well studied. Lyrica is approved for treatment of diabetic neuropathy, a condition often associated with painful burning or numb feet. Diabetic neuropathy is typically the only form of painful neuropathy studied in registration trials due to its high prevalence. The Health Plan recommends Neurontin, tricyclic antidepressants (TCA) or Cymbalta as treatment for diabetic neuropathy prior to consideration of Lyrica.The patient may indeed have glucose intolerance (pre-diabetes). A glucose tolerance test would be appropriate in this setting to further screen for mild or early diabetes. Additionally, the patient should be tried on a TCA such as amitriptyline or nortriptyline, or on Cymbalta. If a trial of a TCA or Cymbalta is ineffective or not tolerable, based on extrapolation from data on the treatment of diabetic neuropathy, as well as the patients good response to the trial of Lyrica, his request for the medication should be reconsidered by the Health Plan. However, based upon the information provided, I have determined the requested medication is not medically necessary for treatment of the patients medical condition at this time. Accordingly, the Health Plans denial should be upheld at this time.
Appeal type: Medical Necessity
Decision: Upheld

The patient has requested authorization and coverage for Norco. This patient has acute presentation of non-specific low back pain, with reports of weakness in the lower extremities. MRI studies of the lumbar spine showed degenerative changes affecting the L5-S1 region of the spine without high grade spinal canal narrowing. The patients provider recommended a physical therapy program and referred the patient to pain management. In this case, non-pharmacologic treatments have not been exhausted and a specific cause of the patients low back pain has not been identified. The current CDC guidelines do not recommend the prescribing of opioid therapy for acute non-specific back pain due to a lack of evidence of benefit combined with risks of dependence, sedation, interruptions of sleep, and gastrointestinal upset. Based upon the medical records available for review and the current medical guidelines, the request for 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 management 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 male enrollee has requested magnetic resonance imaging (MRI) of the left knee in the bent position for evaluation of his left knee pain. Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the requested diagnostic procedure. The medical records provided for review indicate that an ultrasound examination from the date indicated was normal and the MRI on the date indicated was also noted to be normal. In addition, the MRI on the date indicated revealed no definite evidence of meniscal or ligamentous injury and only some nonspecific signal at the patellar tendon. The arthroscopy performed on the date indicated revealed minimal age-related change but no significant pathology. Thus, an MRI with the knee bent would not be expected to add any useful information in the management of this patient as prior MRI studies have revealed no significant pathology. Moreover, the patient has had diagnostic arthroscopy in which a surgeon looks directly at the reported painful area and no significant pathology was identified by the surgeon. Given the multiple unremarkable imaging studies, an unremarkable diagnostic arthroscopy, and recently documented excellent range of motion, indications have not been established for an MRI of the left knee in the bent position. All told, the medical necessity of the requested MRI study has not been established.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for a joint jaw oral device (occlusal orthotic device).Findings:  The physician reviewer found that there is sufficient support for the device at issue in this clinical setting.  Splint therapy has been shown to be beneficial in patients with temporomandibular joint disorder and myofascial pain.  Oral devices have been shown to decrease symptoms in 70 to 90% of cases.  The majority of patients with temporomandibular joint disorder can be treated with a single stabilization splint. Final Result: The reviewer determined that the device at issue was 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 oral and maxillofacial 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 requested authorization and coverage of injectable Hylan G-F 20. The Health Plan denied the request indicating that the requested medication is not medically necessary for treatment of the enrollees knee pain.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested medication is not medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the services for temporomandibular joint dysfunction. Findings:  Three physician reviewers found the current well accepted method to identify the presence or absence of TMJ dysfunction is a comprehensive evaluation of the patients history and clinical examination. There are additional diagnostic tests and studies that are employed in the treatment of TMJ dysfunction. However, the evidence for the use of these modalities in the differential diagnosis or monitoring of TMJ dysfunction and orofacial pain is not supported in the literature. Although, transcutaneous electrical nerve stimulation (TENS) has been used for pain control, its role in the treatment of TMJ dysfunction as compared to traditional therapies has not been demonstrated in the peer-reviewed medical literature. Accordingly, the TMJ dysfunction services were 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 TMJ dysfunction services were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Credentials/Qualifications: Physician reviewers 1 is board certified in otolaryngology with subspecialty certification in plastic and reconstrutive surgery and is actively practicing. Physician reviewers 2 and 3 are board certified in maxillofacial surgery 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: The patient has requested authorization and coverage for pain relief injection. Findings:  The physician reviewer found that vidence based on one high-quality randomized controlled trials in each category the evidence is Level III to II for fluoroscopically-guided caudal epidural injections with moderate to strong recommendation and Level II for fluoroscopically-guided lumbar and cervical interlaminar epidural injections with moderate to strong recommendation for long-term effectiveness. ASIPP further reported that epidural injections have been shown to be effective in managing lumbar spinal stenosis in multiple randomized controlled trials and systematic reviews. A systemic review by Lee and colleagues concluded that lumbar epidural steroid injections were more effective injections than those without steroid for improved pain relief and function for patients with lumbar back pain. This patients records document a history of chronic low back with radiation into the lower extremities. Based on her history and current presentation, the patient has signs and symptoms consistent with neurogenic claudication. An MRI from March 2020 confirmed the presence of moderate-to-severe canal stenosis at L4-5 with an anterior-posterior diameter of 6 mm due to secondary canal changes. She has tried and failed medication management with non-steroidal anti-inflammatory drugs (NSAIDs), opioid medications, and neuromodulating agents. Moreover, she did not obtain adequate relief with physical therapy. Her treating provider has recommended a trial of lumbar epidural steroid injections as a next step in her treatment plan before consideration of surgical options. The current guidelines from ASIPP endorse the use of epidural steroid injections in the treatment of patients with spinal stenosis who have exhausted conservative modalities. Based on these findings, the requested pain relief injection is medically necessary for treatment of this patient. 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 anesthesiology with subspecialty certification in pain management 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: Overturned

A 47-year-old female enrollee has requested magnetoencephalography (MEG) for an evaluation of her arteriovenous vascular malformation (AVM). Findings:  Two physician reviewers found that MEG has been used in a variety of AVM cases with findings of potential advantage in pre-operative planning. MEG is non-invasive, and of low risk. Reduction of operative risk can increase the chance of good functional outcome, with a potential for reduced operative injury to important brain structures. MEG may reduce this patients operative risk, and though not well studied in this specific circumstance, is widely and successfully used for operative planning in epilepsy surgery, where similar considerations of identifying tissue at risk are critical. This MEG request should be approved as it has potential for reducing operative risk, craniotomy size, and surgical outcomes, without risk.
Appeal type: Medical Necessity
Decision: Overturned

The spouse of a 55-year-old female enrollee requested authorization and coverage of continued skilled nursing facility services for treatment following a ruptured brain aneurysm.  The health plan denied the enrollees request indicating that skilled nursing facility services were no longer medically necessary.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.