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

Nature of Statutory Criteria/Case Summary:  An enrollee's parent has requested authorization and coverage for physical therapy, once a week.Congenital muscular torticollis is a common deformity apparent shortly after birth characterized by one-sided cervical lateral flexion and opposite side cervical rotation due to shortening of the sternocleidomastoid muscle. According to medical literature, Outcomes are best when infants are diagnosed early and start comprehensive physical therapy management before three months of age. If untreated or treated after early infancy, congenital muscular torticollis (CMT) can lead to craniofacial deformities, cervical spine dysmorphism, and painful limited cervical motion, requiring more invasive interventions such as botulinum neurotoxin injections and surgery. In this case, the patient was brought to medical attention at two months of age and per the current standard of care was referred to physical therapy. The medical evidence supports the requested services in this clinical setting. Therefore, physical therapy, once a week, is medically necessary for the treatment of the patients medical condition.Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in pediatrics 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 platelet-rich plasma treatment. Findings:  Two of the three physician reviewers found there is a lack of support for the services at issue in this clinical setting. Moraes and colleagues reviewed 17 randomized and two quasi-randomized trials with 1,088 participants. The authors concluded that there is currently insufficient evidence to support the use of platelet-rich plasma therapies for treating musculoskeletal soft tissue injuries. The trials covered eight clinical conditions, including Achilles tendinopathy. Di Matteo and colleagues concluded that there was a paucity of high-level literature regarding the application of platelet-rich plasma in the management of patellar and Achilles tendinopathy. In this patients case, she underwent debridement of the left Achilles tendon with platelet-rich plasma treatment. Per the medical literature, there is insufficient evidence to support the use of platelet-rich plasma treatment in Achilles tendinopathies. There is no compelling rationale presented to support platelet-rich plasma injection over standard therapy in this patients case. Therefore, platelet-rich plasma treatment was not likely to have been superior over other available treatment options. Final Result: The reviewers determined that the services at issue were 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 orthopedic 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: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for consultation with a provider who offers nonoperative regenerative treatment options. In this case, the patient is being treated for osteoarthritis and torn cartilage in the right hip. Progress notes on March of 2021 report moderate persistent bilateral hip pain that interferes with activities of daily living such as walking and hiking. The patient has requested consultation with a provider who specializes in nonoperative regenerative treatment options. Current evidence-based peer-reviewed literature supports decision aids in the orthopedic treatment of patients, utilizing appropriate levels of care for initial evaluation and treatment. Researchers  found that When used in routine care, decision aids are associated with increased knowledge, more shared decision-making, and lower surgical rates. However, there is a lack of adequate data showing improved long-term patient health outcomes with the use of regenerative medicine for the treatment of patients with joint conditions. For these reasons, the requested consultation with a provider who offers nonoperative regenerative treatment options is not medically necessary for this patient. Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in orthopedic 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 me
Appeal type: Medical Necessity
Decision: Overturned

The patient has requested authorization and coverage for Norco 10/325 mg, quantity 150, every 30 days. This patient has a history of spinal cord tumor status post resection. The patients pain has been managed with Norco. For cancer related pain, opiate pain medications such as Norco have a supported role for pain control.  However, Norco 10/325 mg, quantity 300, every 30 days, exceeds the dosing as recommended in the medical literature. Patients can build up tolerance from overexposure for a long period of time with one opiate pain medication. Norco 10/325 mg can still be beneficial for this patient, but should be combined with another medication. The patients treatment plan should include consideration of addition of a long-acting pain medicine, such as a Butrans patch, Nucynta ER or tramadol ER. Given these findings, Norco 10/325 mg, quantity 150, every 30 days is medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that a portion of the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially 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 69-year-old male enrollee has requested radiofrequency neurolysis for treatment of his back pain and lower extremity pain.  Findings:  Two physician reviewers found that the patient underwent a diagnostic block that was shown to provide appropriate response prior to the provider performing the radiofrequency neurotomy. Thus, the patients symptoms are related to facet joint pain rather than radicular pain. Based on systematic review by Datta and colleagues, and applying the guidelines discussed by Manchikanti and colleagues, this patient has been provided with clinically appropriate treatment. Further, the prevalence of facet joint pain has been demonstrated to be 16% in suspected patients and overall 8% in chronic low back pain patients without disc herniation or radiculitis (Manchikanti, et al). Overall, this patient meets the generally accepted criteria for diagnosis of facet joint pain with failed response to transforaminal epidural for nerve root pain. The possible issue regarding a 6-month waiting period prior to repeating the procedure would be satisfied should the patient wait until the said date to undergo the follow-up procedure. As such, the radiofrequency neurotomy was and is indicated and must be approved based on the evidence-based literature and is likely to be more beneficial for management of this patients painful condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 55-year-old woman who had painful keloids of her abdomen including the epigastric/inframmary area of the lower abdomen, which were surgically removed at the time of gallbladder surgery in September 2005. Shortly thereafter, she received radiation therapy in an effort to prevent recurrence of the keloids; unfortunately, some of the painful keloids did recur. The patient was subsequently treated by a dermatologist with intralesional Kenalog with some improvement. Both the patient and her dermatologist want the intralesional Kenalog treatments to continue because the keloids are painful and itchy. The Health Plan has denied coverage for continued follow-up with the patients dermatologist for Kenalog injections on the basis that treatment of the patients keloids is not medically necessary.The treatment of painful, itchy keloids is medically necessary. Pain and itching results in functional impairment. Intralesional corticosteroid treatment is a universally accepted form of treatment for painful, itchy keloids. Dermatologists are the physicians best qualified to administer and assess this treatment because of their training and experience. Therefore, I have determined the requested services are medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for breast magnetic resonance imaging (MRI). The records provided for review document that this patients breast tissue on mammography was described as heterogeneously dense, not extremely dense. The patient was evaluated with targeted ultrasound and diagnostic mammogram which included coned compression spot films and were interpreted as negative. In addition, there are no increased risk factors for breast cancer delineated such as a strong family history or BRCA1 genetic mutation in the patients medical records. While small masses can be obscured by heterogeneously dense tissue, the same limitations of mammography that are present in extremely dense tissue are not present in heterogeneously dense breasts. Given the patients lack of genetic predisposition to breast cancer, heterogeneously dense tissue on mammography, and the negative targeted ultrasound and diagnostic mammogram, the requested breast MRI is not medically necessary for evaluation of this patients medical condition. Final Result: The reviewer determined that the requested diagnostic procedure is not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in diagnostic radiology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 58-year-old male enrollee requested authorization and coverage of the medications Wellbutrin, Neurontin, Seroquel, and trazodone at previously prescribed levels. The Health Plan denied the request indicating that the requested prescriptions are not medically necessary for treatment of the enrollees behavioral health problems.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plans denial on the basis that the requested prescriptions are medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

A 46-year-old female enrollee has requested residential psychiatric treatment for the treatment of her major depressive disorder. Findings:  The physician reviewer found that the medical records indicate that the patient completed family week and was stable on current medication. Two days later, the nursing notes indicated that the patient reported slight depression. However, the nursing notes also indicated no suicidal or homicidal ideation. There was some anxiety, which was responsive to medication.  The medical records demonstrate that the patient was compliant with treatment, was sleeping well and was attending all groups and sharing with peers during the dates of service at issue. Overall, the documentation does not support the medical necessity for continued residential treatment during the time period at issue. Per the American Psychiatric Association guidelines and Level of Care Utilization System (LOCUS) criteria, this patient was appropriate for a less restrictive level of care during the time period at issue. The patient did not meet clinical indications for residential psychiatric treatment during the time period at issue.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Vumerity. The records document that this patient presents with multiple sclerosis that has partially responded to prior therapies. The provider reports that two other medications initially provided symptomatic improvement, but this was followed by intolerable adverse effects. The patient was switched to Vumerity with good response and no side effects. Per the American Academy of Neurology (AAN) practice guideline recommendations, switching the patient to Vumerity, which is a different disease-modifying therapy, was appropriate. The U.S. Food and Drug Administration (FDA) has approved Vumerity as a disease-modifying therapy for patients with relapsing forms of multiple sclerosis, including clinically isolated syndrome, relapsing-remitting multiple sclerosis, and active secondary progressive multiple sclerosis. Given these findings, the requested Vumerity is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in 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

A 42-year-old male enrollee requested authorization and coverage of a sleep study with CPAP machine. The Health Plan denied the request indicating that the requested sleep study is not medically necessary for treatment of the enrollees upper airway resistance syndrome.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.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Ampyra for treatment of her multiple sclerosis. Findings:  The physician reviewer found that the requested medication is medically supported in this clinical setting based upon the submitted documentation as well as evidenced based studies. Ampyra was approved based on primary outcomes in clinical trials that looked at an easily measured feature, walking speed. Studies of more broad health impact from Ampyra have noted improvements in patient-perceived physical and psychological health. A study by Fjeldstad and colleagues found significant improvements in gait, walking speed, distance, and balance were demonstrated by dalfampridine-ER re-initiation after a 10-day withdrawal period. In this patient, Ampyra was shown to improve the patients gait and coordination as documented by the patient and her provider. Since Ampyra has been shown to improve the patients gait and her coordination, its continued use is medically necessary for treatment of the patients multiple sclerosis.  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 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the digital breast tomosynthesis for evaluation of the enrollees breast cancer screening. 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 dense. It is specifically those patients who have dense breasts that can benefit most from tomosynthesis, especially when there are no prior mammograms. The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor. Accordingly, the digital breast tomosynthesis performed was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: The 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: All three 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for magnetic resonance imaging (MRI) of the thoracic spine and lumbar spine for evaluation of the enrollees back pain. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of a portion of the requested services.  The primary reason to obtain an imaging study is if it will alter the course or type of therapy.  With regards to the thoracic spine, the patient has already had one MRI which demonstrated thoracic spondylosis. At this time, he has no significant localizing symptoms other than pain, which the referring practitioner related to muscle pain.  He has no neuropathies, his strength is good, and the physical examination was essentially negative.  Thus, the requested MRI of the thoracic spine is not medically necessary for the evaluation of this patient. In terms of the lumbar spine, the patient is having continued symptoms after surgery.  The American College of Radiology has established appropriateness criteria for several clinical presentations. One of these published lists of criteria describes the appropriateness of studies to evaluate low back pain. For patients with low back pain or radiculopathy and new or progressing symptoms or clinical findings with history of prior lumbar surgery, an MRI is usually appropriate per the criteria.  This patient has had a reasonable trial of conservative management.  It is possible that a lumbar MRI would make a difference in his management.  Following surgery, patients will occasionally develop postoperative seromas, infection (unlikely in this patient), scar formation, or retained bony fragments.  Thus, the requested MRI of the lumbar spine is medically necessary for the evaluation of this patient. Final Result: The reviewer determined that a portion of the requested services is medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be partially overturned. Credentials/Qualifications: The reviewer is board certified in diagnostic radiology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 48-year-old female enrollee has requested a referral to a bariatric surgeon for treatment of her obesity. Findings:  The physician reviewer found that applying the National Institutes of Health (NIH) consensus guidelines, this patient meets the standard definition for clinically severe obesity. The NIH criteria require a BMI of 40 or a BMI greater than 35 with a serious weight related co-morbid condition. This patient has a BMI greater than 35 with a serious weight related co-morbid condition. In addition, she has failed dietary efforts in the past and completed a thorough multidisciplinary evaluation that did not reveal any obvious barriers including medical, endocrine, behavioral or dietary, to surgery. For these reasons, the patient meets all generally accepted criteria for bariatric surgery and therefore the requested referral has been established as medically necessary at this time.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 47-year-old woman with several medical problems including supraventricular tachycardia, asthma, diabetes, and rheumatoid arthritis. She indicates she has difficulty ambulating and therefore, has requested authorization for a power-operated vehicle (POV). The Health Plan has determined a POV is not medically necessary for the patient. A four-wheeled walker has been authorized by the Health Plan to assist with the patients mobility.Review of the submitted medical records does not demonstrate a POV is medically necessary for this patient. The patient has been noted to be ambulatory within her two-story home with a single-point cane. The patient is able to ambulate the stairs using the cane. In addition, based upon the information provided, there is no access in the home for a POV. The Health Plan recommends a four wheeled-walker as an alternative, which in this case is more clinically appropriate. Therefore, I have determined the requested equipment is not medically necessary for the patients mobility. The Health Plans denial should be upheld.