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 sacroiliac joint fusion surgery for treatment of the enrollee who has a history of low back pain. Findings:  2/3 of the physician reviewers found that Sacroiliac fusion is used to immobilize the diseased joint that transmits weight from the spine to the pelvis. The medical evidence indicates that prevention of motion is the only treatment that durably alleviates the pain in the affected sacroiliac joint when non-operative therapies have failed. The recommended sacroiliac joint fusion surgery is in accordance with guidelines and policy statements of major societies. The International Society for the Advancement of Spine Surgery, North American Spine Society and National Institute for Health and Care Excellence (NICE) support the use of fusion for degeneration of the sacroiliac joint where conservative management has failed.  There are also prospective randomized clinical trials on which these guidelines are based. Lastly, these guidelines are also consistent with common community and academic practice patterns. The gold standards of failed non-surgical therapy and response to injections of the sacroiliac joint have been met in this patients case. The requested services are consistent with guidelines, data and medical standards referenced above. In summary, sacroiliac fusion is likely to be more beneficial in the treatment of this patient than other treatment options. Final Result: 2/3 of the reviewers determined that the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewer number one is board certified in neurological 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.Physician reviewer number two is board certified in neurological 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.Physician reviewer number three is board certified in neurological 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

Findings:  The physician reviewer found that the patient has requested authorization and coverage for Nucynta ER 200 mg. In this case, the patient has a neurological history that includes Chiari malformation and headaches. In addition to surgery to correct the Chiari malformation, the patient has undergone several ventriculoperitoneal shunt surgeries and suffered an infectious complication from one of his procedures. The patient reports a daily pressure like headache. While the submitted documentation reflects that the patient has tried CGRP inhibitors, valproic acid, topiramate, and other opioid analgesic medications, there is no indication that the patient has tried other therapies such as nortriptyline or verapamil. Under these circumstances, Nucynta ER 200 mg is not medically necessary to treat the patients medical condition. 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 neurology 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 bilateral custom foot orthotics.Mortons neuroma is a benign neuroma or lesion of an intermetatarsal plantar nerve, most commonly of the second and third intermetatarsal spaces. Custom orthotics have been considered a standard of care treatment for Mortons neuroma for many years. Custom orthotics, specifically with a metatarsal raise pad, allow for alteration in the biomechanics of the foot, allowing for reduction in stress, strain, and pressure to the Mortons neuroma. Current studies advise that custom orthotics with a metatarsal raise pad are indeed efficacious and alter the biomechanics of the foot to allow for pain-free ambulation for patients with neuromas. In this case, physical examination and MRI evaluation demonstrate a painful neuroma to the second intermetatarsal space. The patient has failed numerous conservative treatments. There is sufficient support for the requested equipment in this clinical setting. Therefore, the requested bilateral custom foot orthotics are medically necessary for the treatment of the patients medical condition.Final Result: The reviewer determined that the requested equipment 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 podiatry 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 20-year-old female enrollee requested authorization and coverage of orthognathic surgery for the treatment of skeletal malocclusion.  The Health Plan denied the enrollees request indicating that the requested treatment is 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 surgery is not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:   An enrollee has requested inpatient level of care services for treatment of her behavioral health conditions.  Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the services at issue.  This patient was at risk for undue morbidity, self-harm and prompt re-admission to the acute level of care in the event of a premature discharge.  The patient had neither consolidated the treatment gains nor resolved the ambivalence necessary to successfully follow through with treatment in a less restrictive setting.  The disputed treatment course consisted of active treatment reasonably expected to prevent a more serious episode of illness while improving her condition.  All told, inpatient level of care services was medically indicated for the treatment of this patient.  Final Result: The reviewer determined that the services at issue were 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 sub-specialty 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

A 52-year-old male enrollee has requested for coccydynia surgery for treatment of his coccygodynia. Findings:  The physician reviewer found that the criteria for patient selection for coccygectomy are not well-defined.  With patients showing radiologic evidence of instability, such as hypermobility on lateral dynamic radiographs, and failure of adequate conservative treatment, good results can be obtained.  However, most patients respond to conservative therapies, such as local injections.  A significant complication rate has been reported for the requested surgery.
Appeal type: Medical Necessity
Decision: Overturned

A 40-year-old female enrollee has requested vagal nerve stimulator implantation for treatment of her epilepsy.  Findings:  The physician reviewer found that this patient has a history of refractory seizure disorder, as well as possible non-epileptic seizures.  Per the submitted medical records, electroencephalography has given indication of localization of specific seizure source.  The patient has had continued high seizure frequency despite concurrent use of three anticonvulsants, with reported fatigue, which may be a medication side effect.  The current medical literature shows that vagal nerve stimulation can be beneficial in reducing seizure frequency in patients with partial onset seizures who have failed adequate control with medications.  Vagal nerve stimulation is medically appropriate for the management of medically-refractory seizures.  All told, the requested vagal nerve stimulator implantation is medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Overturned

The parents of a five-year-old male enrollee have requested for occupational therapy for treatment of the enrollees pervasive developmental disorder.   Findings:  Two physician reviewers found that occupational and speech treatments are not considered experimental for this diagnosis.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for endovenous ablation therapy. Researchers noted that in a study of 1,406 patients with varicose veins, endovenous treatment of axial reflux was the preferred treatment in 89.1%, divided largely between radiofrequency ablation at 55.2%, and endovenous laser ablation at 33.9%. In this case, the patient has reflux of the vein to be treated and arterial perfusion to the lower extremities. Given that the records note that the patient is a candidate for vein ablation, and that her symptoms are of a severity to limit daily activities despite efforts at conservative treatment, the requested service is medically indicated. Therefore, endovenous ablation therapy is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested service 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 vascular 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

The parents of a 20-year-old male enrollee requested authorization and coverage of a referral to the New Start Community Re-Integration Program for rehabilitation of C4-5 complete ASIA Class A quadriplegia.  The Health Plan denied the enrollees request indicating that the requested treatment is 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 services are not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 64-year-old female enrollee has requested Alinia 500mg for the treatment of her blastocystis hominis colitis. Findings:  The physician reviewer found that potential medications for treating the patients condition include the antibiotic metronidazole (Flagyl), the combination medication sulfamethoxazole and trimethoprim (Bactrim, Septra and others) and the antiprotozoal medication iodoquinol. It would have been medically appropriate to have treated the patient with Flagyl or Septra, and to have considered Alinia if she failed to respond to these antibiotics. As such, the Health Plans denial was medically appropriate.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 62-year-old woman with severe persistent asthma. A spirometry performed in December 2004 showed a normal pattern on the flow-volume loop and an FEV1 of 127% of predicted value. According to the information provided, the patient was unable to perform a post-bronchodilator test because she fainted. Her pulmonologist read the study as within normal limits. The patient has requested coverage for use of Xolair in treatment of her asthma. A note dated May 2005 from her primary care physician states the patient has had multiple flares resulting in multiple corticosteroids treatments, putting the patient at risk for hyperglycemia and osteoporosis.The Health Plan has denied coverage for Xolair indicating the patients IgE level was beyond the recommended treatment level and she did not have demonstrable airway reactivity, indicated by an increase in FEV1 after bronchodilator challenge. The patients IgE level was 728 IU/ml and she weighed 159 pounds (72.2 kg).At issue is whether Xolair is medically necessary for treatment of the patients medical condition.Xolair is indicated in patients with moderate to severe asthma and positive skin test reactivity to aeroallergens. This initial study had patients with FEV1 between 40-80% of predicted value, a change of FEV1 of more than 12% after bronchodilators, with total IgE between 30-700 IU and a body weight of less than 150 kg.According to the records provided, the patients IgE level is above the 700 IU criteria. The dosing chart provided by the drug manufacturer states that patients with levels above 700 IU should not be dosed. Though there is a need to reduce the use of systemic corticosteroids, it appears other diseases such as allergic bronchopulmonary aspergillosis, vocal cord dysfunction or other pulmonary illnesses, which may mimic asthma, should be considered. In any event, the use of Xolair is not medically indicated based upon the information provided. Therefore, I have determined that the requested medication is not medically necessary for the treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested 56 hours per week of licensed vocational nurse (LVN) services, early and periodic screening and diagnosis and treatment (EPSDT) for treatment of the enrollees medical condition.  Findings: The physician reviewer found that based upon a review of the information provided, as well as the available medical literature, the request for 56 hours per week of LVN services, EPSDT for the patient is medically necessary. The patient has skilled needs which include medication administration, pulmonary clearance therapies, gastrostomy tube feeding, oral suctioning, and monitoring for oxygen desaturation and airway obstruction related to his underlying respiratory problems and obstructive sleep apnea (OSA), and potential administration of supplemental oxygen and repositioning or stimulation in the event of apnea. His mother is a single mother who works outside of the home seven days a week. Given the absence of a skilled caregiver in the home to meet his needs when the mother is working, the frequency of his gastrostomy tube feeding, his medication administration, and his respiratory care needs, medical necessity for skilled nursing services exists. Additionally, per the documentation provided, it appears the patient was previously approved for 56 hours per week of LVN services. The care needs of the patient do not appear to have changed, so it is unclear as to why it would have been determined that the nursing requirements of the patient have changed. Care of medically complex children such as the patient is a significant source of stress for parental caregivers, and community-based resources like skilled nursing are critical factors that facilitate safe care in the home. Considering the information provided for the review and the available medical literature, the requested LVN services are medically necessary for the patient.  Final Result:  The physician 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 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: Experimental/Investigational
Decision: Overturned

A 51-year-old female enrollee has requested for Avastin for treatment of her metastatic breast cancer. Findings:  Three physician reviewers found that Avastin is a monoclonal antibody that targets vascular endothelial growth factors and presumably treats cancer by inhibiting tumor vascularity. It has been approved for use in several types of cancer, when given with chemotherapy.In breast cancer there is a randomized trial comparing the efficacy of Taxol with and without Avastin as first line chemotherapy for metastatic breast cancer. Indeed this study demonstrated a better response rate as well as a longer time to cancer progression with the combination. As mentioned, this was a first-line study and did not involve patients such as this patient who have been heavily pretreated.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for weekly individual psychotherapy. Findings:  The physician reviewer found that the records document that the patient continues to endorse significant symptoms of anxiety and depression despite numerous medication trials and seeing numerous providers, including psychiatrists, therapists, pharmacists, and group clinicians. Her symptoms of depression and anxiety and overall functioning have worsened. The records note that the patient seeks out individual therapy and improved with individual contact. Given the patients symptoms of anxiety and depression, along with possible additional diagnosis of personality disorder, weekly individual psychotherapy is medically indicated. In this patients case, weekly individual psychotherapy is in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, the requested services are clinically appropriate in terms of type, frequency, extent, site, and duration. The requested services are not primarily for the economic benefit of the health care service plan and subscribers or for the convenience of the patient, treating physician, or other health care provider. Therefore, weekly individual psychotherapy is medically necessary for the 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 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: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Jakafi 10 mg for treatment of the enrollees graft versus host disease (GVHD). Fulfills requirements of (1374.33) (h)(1)(A), (B), and (C). Findings:  The physician reviewer found that patients who have undergone allogeneic hematopoietic stem cell transplant (allo-HSCT) are at risk for acute graft versus host disease (GVHD) (Flowers, et al). Immunosuppressive therapy is indicated and Jakafi is increasingly being recognized as a potent agent for use in this clinical setting. Jakafi is an ATP-competitive inhibitor of Janus kinases 1 and 2. In a retrospective survey of multiple transplant centers, Jakafi was effective in controlling steroid refractory GVHD in 80% of patients .  There is sufficient medical evidence to show that Jakafi has a role in patients who have exhausted standard treatment. As this patient has exhausted standard treatment, the requested Jakafi 10 mg is supported as medically necessary for treatment of this patients GVHD. Fulfills requirements of (1374.33)(h)(1)(H) and (K).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. Fulfills requirement of 1374.33(h)(1)(I) Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certifications in medical oncology and hematology 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. Fulfills requirement of (1374.33)(h)(1)(G)
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 43-year-old pregnant female with a history of bipolar disorder. The patients psychiatrist indicates the patient has been relatively unstable with depression that has affected her concentration, memory, and ability to work. In addition, the patient is currently being monitored off medications until the end of her pregnancy and into the post-partum period. The patient has requested authorization to continue to receive treatment from her current psychiatrist. The Health Plan indicates appropriate services are available from an in-network provider, and therefore, are not medically necessary.The patient has had a long-term relationship with her current psychiatrist. The patient is currently stable, however, she is pregnant. It is not in the patients interest to disrupt continuity of care at this juncture. Clinical monitoring by a psychiatrist familiar with the patient is essential during pregnancy in a patient with a history of bipolar disorder. Thus, the patients psychiatrists request to follow the patient through delivery and into the post partum period is medically reasonable and standard of care. Therefore, I have determined that the requested services are medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned. The patient should continue to be followed by her current psychiatrist for a six-month period following delivery.
Appeal type: Medical Necessity
Decision: Upheld

An 18-year-old male enrollee has requested for skin therapy and acupuncture for treatment of his acne. Findings:  The physician reviewer found that there is a lack of controlled trials in the medical literature supporting acupuncture and laser therapy in this clinical situation.  The current medical evidence does not support the requested services in this patients case. All told, laser therapy and acupuncture are not medically indicated for the treatment of this patient.