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

A 63-year-old female enrollee has requested skilled nursing services for treatment of the enrollees fractured sacrum.   Findings:  The physician reviewer found that pelvic fractures, the sacrum being part of the pelvic girdle, are painful. The time for resolution of the pain can be extensive. It is important for such patients to receive adequate support to maintain and restore function during the prolonged healing period. However, daily skilled rehabilitation services do not remain medically necessary throughout the entire healing period. In this patients case, the records document she had adequate pain control and had reached modified independent to contact guard function for all activities. Clinical studies have found that rehabilitation can be accomplished as effectively at home as in a facility in this setting (Ward, et al.). The patient has reached a level of function that does not require daily skilled therapy to restore or maintain function. There is no indication of any daily skilled nursing needs. Continued improvement in function can be achieved with continued exercise without daily supervision from a skilled therapist.  As such, the requested skilled nursing services are not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for Humira 40 mg/0.4 mL pen, quantity of four per 28 days. There is a lack of evidence in current medical literature supporting the use of the requested medication regimen for the treatment of enthesitis-related arthritis subtype of juvenile idiopathic arthritis and juvenile ankylosing spondylitis. Mistry and colleagues note that management of enthesitis-related arthritis includes NSAIDs with physical therapy. The American College of Rheumatology/Arthritis Foundation guideline for the treatment of juvenile idiopathic arthritis reports that, In children and adolescents with active sacroiliitis despite NSAIDs, adding a tumor necrosis factor inhibitor (TNFi) is strongly recommended over continued NSAID monotherapy. Burgos-Vargas and colleagues note in a randomized, double-blind, placebo-controlled multicenter of pediatric patients with enthesitis-related arthritis treated with a maximum Humira dosage of 40 mg every other week, Humira reduced the signs and symptoms of enthesitis-related arthritis at week 12, with improvement sustained through week 52 compared to placebo. In a double-blind, placebo-controlled randomized trial with adalimumab for the treatment of juvenile onset ankylosing spondylitis by Horneff and colleagues, study participants also received Humira every other week. The authors noted that the use of Humira resulted in a significant decrease in juvenile ankylosing spondylitis disease activity parameters at week 12, compared to placebo, was even more pronounced at week 24. In this case, the patient is currently on Humira, a TNFi, at the dosage and frequency approved by the U.S. Food and Drug Administration (FDA). While weekly dosing of Humira may be used for the treatment of Crohns disease, in this case, the records note that the patients inflammatory bowel disease symptoms are controlled on Humira every other week. In this clinical setting, given the lack of evidence in current medical literature supporting a dose escalation for the treatment of enthesitis-related arthritis in pediatric patients, the requested medication regimen is not medically indicated. Therefore, Humira 40 mg/0.4 mL pen, quantity of four per 28 days, is not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested medication regimen 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 sub-specialty certification in rheumatology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Humira monitoring tests. The Health Plan has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees medical condition.Findings:  There is currently insufficient medical evidence to support the superior efficacy of Anser ADA when compared with conventional courses of action in the management ulcerative colitis. The published studies on the use of anti-adalimumab antibodies and serum levels are small, retrospective, and/or observational rather than controlled in nature, preventing firm conclusions about cause and effect (Morita, et al; Roblin, et al; Ungar, et al). These small studies at best demonstrated correlations between treatment failure and the presence of anti-adalimumab antibodies, which do not allow firm conclusions regarding cause and effect. Additionally, the ATLAS study showed that patients with loss of response may actually have high, rather than low, serum levels (Yarur, et al). It is possible that active disease results in low adalimumab levels due to loss of adalimumab, rather than low adalimumab levels resulting in loss of disease control. Moreover, controlled studies are lacking to show that use of the test results in improved long-term health outcomes for patients with ulcerative colitis compared with conventional management. All told, there insufficient evidence from controlled studies to definitively demonstrate that the Humira monitoring tests  were likely to have been more effective than the available standard therapies for managing this patients medical condition.Final Result: All three reviewers determined the services at issue were 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:  All three reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology 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: Upheld

This patient is a 49-year-old female who began Bicilllin injections for the treatment of chronic Lyme disease in late 2005. She has also been treated for extended periods (i.e. several months) with oral antibiotics including rifampin, doxycycline and ciprofloxacin. There are a large number of serological tests for Ehrlichiosis included in the record. All of those for human monocytic Ehrlichiosis are negative; several of those for human granulocytic Ehrlichiosis are at or above the titers that may suggest disease states, most notably an IgG of greater than 1:640 in May 2005. The patients request for reimbursement for three Bicillin purchases made between March 2006 and August 2006 was denied by the Health Plan based upon a determination that the medication was not medically necessary.The duration of therapy for any form of late Lyme disease (e.g. arthritis or neurological disease) recommended by the Infectious Disease Society of America (IDSA) is a maximum of four weeks. The patient has received at least five months of treatment with Bicillin for her Lyme disease. Application of the CDC criteria to her Western Blot results does not allow a diagnosis of Lyme disease and specific clinical findings indicative of this infection are also lacking. In the event a diagnosis of Lyme disease was substantiated, there is no support from peer-reviewed studies for a treatment period of over 30 days. Evidence of Ehrlichiosis is also lacking as there is no documentation of clinical symptoms and no IgM response documented among the frequent tests for this disease. Even if this diagnosis was substantiated, Bicillin is not the recommended therapy and the patient had been more than adequately treated with the oral antibiotics she was given. Based upon the information set forth above, I have determined the medication at issue was not medically necessary for 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 patients parent has requested authorization and coverage for weekly speech therapy. Based on the available documentation, this patient with autism and Down syndrome has participated in speech therapy for several years with slow progress. In July 2020, the provider reported that the patient has met one of six goals, significant progress in two of six goals, and progress in the remaining three goals. According to the National Down Syndrome Society (NDSS), patients with Down syndrome frequently have difficulty with grammar, tenses and word endings and use shorter sentences to communicate. In the medical literature, researchers noted that language disorder is a cardinal challenge for children with Down syndrome and these patients have the potential to respond to language intervention. A study noted that the achievement of speech intelligibility by patients with Down syndrome facilitates their participation in society. Given this patients slow progress with speech therapy thus far, continued weekly speech therapy is consistent with current medical literature recommendations. Moreover, the requested weekly speech therapy is medically necessary to decrease disability due to speech and language impairment and promote health and efficiency by decreasing her frustration with her difficulty in communication with others. For these reasons, the requested weekly speech therapy 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 neurology with special qualification in child 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: Upheld

Nature of Statutory Criteria/Case Summary:   An enrollee has requested Vicodin for treatment of her medical condition.  Findings:  The physician reviewer found that based on the clinical documentation submitted for review, the medical necessity for the requested medication has not been established. The current standard of care for acute onset back pain is conservative therapy treatment to include physical therapy, massage therapy, cognitive behavioral therapy, and injections to help reduce pain. Opiates are considered adjunctive to this therapy after failing a trial of conservative therapy. Researchers reported that high dose and short acting 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. The submitted records do not document the patient has failed conservative therapy. Based on the clinical documentation and peer-reviewed literature, the patients request for Vicodin is not medically necessary.  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 and 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested breast tomosynthesis performed for evaluation of her breast pain. Findings:  Three physician reviewers found that while there is a lack of long-term studies demonstrating increased survival rates when tomosynthesis has been added to the usual screening mammography protocol, the addition of the technique has gained worldwide support among providers due to an associated significant decrease in callbacks and increased detection of small cancers. This advantage is due to the tomographic quality of digital tomosynthesis and the advantage of having the ability to eliminate the confusion and artifact of glandular breast tissue either mimicking or obscuring a mass. Thus, the addition of the technique is considered more beneficial for the patient than mammography alone. Consistent with these findings, the breast tomosynthesis performed was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: Three reviewers determined that the diagnostic procedure at issue was 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: Reviewers 1, 2, and 3 are board certified in diagnostic radiology 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 62-year-old female has requested diagnostic genetic testing for evaluation of her stage IV ovarian cancer.  Findings:  The physician reviewer found that the National Comprehensive Cancer Network (NCCN) guidelines indicate that genetic testing is indicated for patients with a diagnosis of epithelial ovarian cancer. In addition, the U.S. Preventive Services Task Force (USPSTF) and American College of Obstetricians and Gynecologists (ACOG) endorse the utility of diagnostic genetic testing to assist in treatment planning for patients with epithelial ovarian cancer. All told, the requested diagnostic genetic testing is supported as medically necessary in evaluating and treating this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The parent of an eleven-year-old male enrollee has requested for foot orthotics and follow-up with a podiatrist for treatment of the enrollees bilateral pes planus. Findings:  The physician reviewer found that orthotics is medically indicated for children with structural deformities, hallux valgus deformities and abnormal gait. These findings are not supported in the documentation provided. Foot orthotics is indicated for pes planus when there is documentation to support a fixed arch or a severe ankle varus. Diagnoses of corns, calluses and hammertoes usually respond to over-the-counter inserts and shoe modification. The patient has yet to fail on conservative treatment consisting of rest, ice, over-the-counter gel inserts, injections or medications to decrease inflammation, splints, exercises and immobilization.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 13-year-old male enrollee has requested for speech therapy services for treatment of the enrollees laryngospasm and stuttering.  Findings:  The physician reviewer found that the services at issue include video speech therapy (telehealth) which has been shown to be effective in curing stuttering, according to Carey and colleagues. In their controlled study, the authors concluded that telehealth is as effective as face-to-face therapy. In this case, the providers therapeutic intervention has resulted in significant speech improvement as demonstrated in the patients records.
Appeal type: Medical Necessity
Decision: Overturned

A female enrollee requested authorization and coverage for gastric bypass surgery.  The health plan has denied this request indicating that the requested surgery is not medically necessary for treatment of the enrollees morbid obesity.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer overturned the health plans denial on the basis that the requested procedure is medically necessary
Appeal type: Urgent Care
Decision: Upheld

A 28-year-old female enrollee has requested for an emergency room visit for treatment of her abdominal pain and umbilical infection. Findings:  The physician reviewer found that she did not require any pain control in the emergency department. This patients symptoms were not acute in nature but rather were chronic. There is not evidence to support that an emergency existed in this case.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for transoral incisionless fundoplication (TIF) with EsophyX (CPT 43210). Appropriate patient selection is crucial before anti-reflux procedures. In prelude to surgical intervention for gastroesophageal reflux disease (GERD), authours noted that, upper endoscopy, barium esophagram, pH testing, and manometry are required for preoperative workup for antireflux surgery. This patient has undergone some of this preoperative assessment. The available records do not support that the patients GERD is advanced, or that there is good correlation of symptom benefit with acid suppression. The current medical literature supports a possible indication for TIF in patients with Hills grade I-II, no hiatal hernia or hernia up to 2 cm. However, in this patients clinical scenario, there is no documentation of formal esophageal function testing or pH studies to establish that the patients symptoms objectively correlate with acid reflux events. Furthermore, in patients who have objectively demonstrated refractory GERD, current medical literature has not demonstrated the superiority of TIF versus laparoscopic Nissen fundoplication. All told, the requested TIF with EsophyX (CPT 43210) is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings:  Three of the three physician reviewers found the requested TIF with EsophyX (CPT 43210) is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested 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: Physician reviewers 1, 2, and 3 are board certified in internal medicine with subspecialty certification in gastroenterology 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

The patient is a 50-year-old man with a history of nasal fracture from boxing. There is documentation of several severe episodes of epistaxis in the providers treatment notes. In addition, the submitted treatment notes document a severe, acute angled, septal deviation, which is consistent with a nasal fracture. The patients provider has recommended nasal surgery to repair the deviated septum. The Health Plan indicates that the requested procedure is not medically necessary.The American Academy of Otolaryngology (AAO) recommends a septoplasty to repair severe nasal obstruction; recurrent epistaxis; atypical facial pain/recurrent sinusitis; or to allow surgical access to other intranasal/sinus structures. Upon review of the submitted clinical information, there is documentation that the patient has a severe nasal obstruction and recurrent epistaxis. In light of the fact that the patient meets AAO clinical indications for nasal surgery, the requested procedure is medically indicated. Therefore, I have determined that the requested procedure is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Upheld

A 47-year-old female enrollee has requested Synvisc-One injections for treatment of her left hip osteoarthritis.  Findings:  Three physician reviewers found that the use of viscosupplementation at the hip is not adequately supported by the current practice guidelines and available research as there is no basis for use of viscosupplementation for treatment of osteoarthritis in the hip. The use of viscosupplementation within the knee joint is generally accepted (Bellamy and colleagues). However, the efficacy of viscosupplementation in joints other than the knee joint remains controversial (Richette and colleagues). These authors conducted a multicenter, randomized, placebo-controlled, trial with three-month follow-up assessment. They found no significant difference between treatment with viscosupplementation injection and placebo. Given the paucity of studies establishing improvement in patient outcomes with use of viscosupplementation in the hip joint, the therapy remains of questionable efficacy in this setting.