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

The patient is a 61-year-old male with an apparent diagnosis of post concussion syndrome secondary to a head injury in late 2004.  There is neuropsychological testing consistent with the stated diagnosis and a brain MRI with no abnormal findings.  The patient has requested authorization for cognitive rehabilitation therapy. The Health Plan denied his request based upon a determination that therapy is not medically necessary for the treatment of his post concussive syndrome.According to the literature, a `cognitive therapy program` which consists of physical, occupational, speech and or psychotherapy, is indicated when there has been head trauma with evidence of brain injury, deficits in specific areas of functioning, and less than six months has passed since the brain was compromised. Although there is an inference that a `program` is necessary, the record provided does not support such a global need and well over six months have passed. The injury in this case, `post-concussion syndrome,` is mainly evidenced in this individual by depression, anxiety, and memory problems, approximately 18 months after the fact. There is no apparent need for the multidisciplinary approach typical of a cognitive rehabilitation program.  If the patient wished to pursue psychotherapy for treatment of his depression and anxiety, he might benefit from some cognitive training techniques incorporated into the course of that treatment. Based on the evidence cited above, I have determined the requested therapy is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

The parent of a 12-year-old female enrollee requested a water circulating cold pad with pump for medical treatment of the enrollee, who is status post knee surgery.  Findings:  Three physician reviewers found the current medical evidence has not demonstrated that simple methods of applying cold in the postoperative period are less effective than circulating cold pads with and without alternate compression.  While cryotherapy in the immediate postoperative period has been demonstrated to be beneficial in terms of pain control, it is not necessary to utilize a water circulating cold pad with pumps to provide cold therapy.  Thus, the water circulating cold pad with pump was not likely to have been of greater benefit than other available alternatives.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 53-year-old female with type I diabetes. Her comorbidities include retinopathy, very mild neuropathy, peripheral vascular disease and hypertension. She uses Humalog, Lantus and Novolog to manage her blood glucose levels. She has also been prescribed Adipex, Celexa, Diovan, L-Arginine, Levoxyl, Lexapro, Vicodin, Xanax, Singulair and Zonegran.  The patients provider noted that the patients fasting glucose and hemoglobin A1C were inappropriately high, apparently based on a review of her home-glucose monitoring. There is no data available for her home-glucose monitoring or hemoglobin A1c laboratory analysis.  CGMS data are available for eighteen hours in July 2005 as well as the results of her sensory testing. The patient has requested reimbursement for the procedures. The Health Plan denied the request based on a determination that the procedures were not medically necessary.Continuous glucose monitoring is typically an adjunct to home-glucose monitoring to assist in the insulin management of a patient. It may also be useful in detecting nocturnal hypoglycemia and elevated postprandial blood glucose levels. However, in many cases similar information can be obtained by consistent daily monitoring and recording of pre-and postprandial and nocturnal blood glucose levels. There are no blood glucose records available for this patient, but based on her providers notes there was no record of unexplained hypoglycemia. Similarly, it did not appear to be a situation where the patient demonstrated accurate frequent blood glucose testing and there was no correlation with her hemoglobin A1C or blood glucose levels performed by laboratories.  Based on the records provided, there was no clear medical indication for CGMS for this patient.This patients quantitative sensory testing showed very mild peripheral neuropathy. Monofilament, vibrations or pinprick testing may provide similar information. This test is considered investigational as long-term clinical outcome data are not available and it should not replace conventional nerve testing.Based upon the information set forth above, I have determined the procedures at issue were not medically necessary for evaluation of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

A 61-year-old female enrollee has requested an increase of medication Lyrica (pregabalin) to 100mg taken every 6 hours, 4 times daily for treatment of her neck, low back, right hand and right hip pain.  Findings:  The physician reviewer found that review of the submitted documentation and relevant literature demonstrates the medical necessity of the requested medication. The use of Lyrica (pregabalin) in the higher doses requested meets criteria for medical necessity because this treatment in this specific patient has been shown to be more effective than other failed treatment regimens and it is well tolerated by this patient and is consistent with published literature as well as standard of care. Although most patients will respond dosing of 300mg or below, numerous publications have demonstrated that the drug in question has efficacy and safety in doses up to 600mg per day for neuropathic pain (Boyle et al). Moore and colleagues specifically note that, Individualisation of treatment is needed to maximise pain relief and minimise adverse events. By titrating the dose higher to the patients requested dose, the physician in this case has individualized the treatment as called for. Additionally, other alternative treatments (i.e., opiate medications, procedures, etc.) are associated with risk. For the reasons set forth above, Lyrica 100mg taken every 6 hours, 4 times daily is medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

An enrollee has requested reimbursement for a DecisionDx-Melanoma gene assay. A study found the use of gene expression profiling in patients with stage 1-2 melanomas as a risk stratification tool in patients with melanomas with high risk features. In this patients case, the records document melanoma with a thick Breslow depth transected at initial biopsy, negative surgical margins on wide local excision, and negative sentinel lymph node biopsy.  Based on the initial pathology report, the patient appeared to have an increased risk of cancer recurrence. The DecisionDx-Melanoma gene test assesses the risk of recurrence based on the genetic expression profile. In this patients case, the DecisionDx-Melanoma gene test showed a lower risk profile and, therefore, changed management to include less frequent skin examinations and surveillance imaging. This is superior to standard of care, which includes excision, sentinel lymph node biopsy, and routine skin examinations scheduled at arbitrary intervals. Therefore, the DecisionDx-Melanoma gene assay was likely to have been more beneficial than any other available standard service for the patients medical condition.Final Result: The reviewers determined that the services at issue were 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 reviewers 1, 2, and 3 are board certified in dermatology 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 parent of a five-year-old male has requested speech therapy and occupational therapy services for treatment of his autism. Findings:  The physician reviewer found that the medical literature supports both speech therapy and occupational therapy in the autistic population. Concerning the requested speech therapy, the report by Myers, et al. is frequently cited in the autistic literature as a definitive source for the evaluation and treatment of autistic children. It is concluded in this report that, people with autism spectrum disorders (ASDs) have deficits in social communication, and treatment by a speech-language pathologist usually is appropriate. Most children with ASDs can develop useful speech, and chronologic age, lack of typical prerequisite skills, failure to benefit from previous language intervention, and lack of discrepancy between language and IQ scores should not exclude a child from receiving speech-language services (Myers, et al.). In a controlled study comparing autistic children who did and did not receive speech therapy, those who received therapy had far greater communication skills than children who did not receive speech therapy (Turner, et al.). The Speech and Language Association also states that autistic children can benefit from speech therapy. This report emphasizes that age, either early or late in life, is not a barrier to speech therapy. Occupational therapy is an efficacious therapy for reducing many of the unwanted mannerisms associated with autism (Pfeiffer, et al.). May-Benson and Koomar performed a meta-analysis of 27 journal articles utilizing sensory integration occupational therapy techniques for autistic children and concluded that the therapy was effective.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:   An enrollee has requested atovaquone (Mepron) for treatment of her diagnosis of Lyme disease. The physician reviewer found that as noted by Lantos and Wormser, there is a lack of evidence of chronic Babesia infection in immunocompetent persons in the absence of fever, laboratory abnormalities and detectable parasitemia. The serological data cited as the reason for treating this patient for Babesia duncani infection is inadequate. There is no four-fold change in antibody titer, evidence reported from polymerase chain reaction (PCR) studies, or blood smears that parasitemia has been documented. In the absence of studies demonstrating the presence of chronic Babesia infection, the requested Mepron medication is not medically necessary for treatment of this 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 internal medicine with sub-specialty certification in infectious diseases 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 artificial disc replacement surgery for C4-5, C5-6 and C6-7. Current medical literature supports the use of multilevel cervical disc arthroplasty at three or four levels. In an evaluation of 159 cervical disc arthroplasties (CDAs), Gornet and colleagues concluded that statistical improvement in patient-reported outcomes, with a low rate of secondary surgeries out to seven years, demonstrated that three and four level CDAs were safe and effective in appropriately selected patients. Reinas and colleagues report that multilevel CDA provides good clinical and radiological outcomes, preserving motion in the cervical spine and preventing adjacent segment degeneration, while having a beneficial effect on sagittal balance. The authors further note that these results are true for two to four levels, making the procedure a valuable option in patients with cervical multilevel degenerative disc disease. In this case, the records document the presence of degenerative disc disease with radiculopathy at multiple levels despite conservative treatment and the severity of the symptoms. Given that current medical literature supports the use of the requested service as effective for pain relief, improvement of function, preservation of motion, and long-term efficacy, the requested service is medically indicated. Therefore, artificial disc replacement surgery for C4-5, C5-6 and C6-7 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 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 medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for an implantable ambulatory event monitor. The records provided for review document that this patient experienced episodes of dizziness prior to the syncopal episodes. Evaluation with a Holter monitor several months before was unrevealing. He presented with chest pain followed by recurrent acute syncopal episodes and he was noted to be in atrial fibrillation, which responded to chemical cardioversion. He was evaluated for underlying causes of syncope including coronary artery disease (CAD). An echocardiogram demonstrated normal left ventricle (LV) function. The recurrent episodes of syncope, prior negative Holter results, and history of known paroxysmal atrial fibrillation supported concern for an arrhythmic cause of his syncope. As noted in the medical literature, implantable loop recorders have a specific clinical role in this patients scenario. The likelihood of a rhythm disturbance was high given the known prior atrial fibrillation and recurrent witnessed syncope along with infrequent events, and other explanations including CAD and LV dysfunction were ruled out. Earlier use in these situations has been shown to result in higher diagnostic yield with earlier diagnosis of the rhythm disturbances that inform subsequent treatment decisions. In this case, following several months of monitoring, sick sinus syndrome was confirmed, and a pacemaker implanted. All told, the implantable ambulatory event monitor was medically necessary for this patient.Final Result: The reviewer determined that the services at issue were medically necessary for evaluation 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 cardiovascular disease 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 Prometheus Anser IFX blood testing. Findings: Two of the three physician reviewers found that the Prometheus Anser IFX blood testing was not indicated under these circumstances. The Prometheus Anser IFX blood test has not definitively demonstrated efficacy for the management of Crohns disease. The presence of antibodies alone does not necessarily result in loss of response to infliximab or infusion reactions, nor have threshold levels been established. Studies have found that anti-infliximab antibodies can be transient, and disappear over time, with many patients who have these antibodies maintaining their response. The current medical literature lacks high-quality controlled studies to define drug level or antibody level thresholds requiring action, compare clinical strategies (such as dose increase or change in medication) based on those thresholds, and then definitively establish that use of Anser IFX improves outcome. The test can be redundant with other methods of disease assessment, such as enteroscopy and magnetic resonance enterography, which were used for decision-making in the case. For these reasons, the Prometheus Anser IFX blood testing performed for this patient was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: Two of the three reviewers determined that the services at issue were not likely to be more beneficial for treatment of the patients medical condition than any other available standard treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: All three reviewers are board certified in internal medicine, with subspecialty certification in gastroenterology, and all three 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

A 40-year-old female enrollee has requested authorization and coverage for continued physical therapy. The Health Plan has denied this request indicating that the requested therapy is not medically necessary for treatment of the enrollees degenerative disc disease.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested therapy is not medically necessary.
Appeal type: Experimental/Investigational
Decision: Overturned

A 35-year-old male enrollee has requested RT300-S functional electrical stimulation cycle ergometry system for treatment of his T3 spinal cord injury. Findings:  Two physician reviewers found that although functional electrical stimulation cycle ergometry is not indicated for many patients with neuromuscular disease, there is evidence in the form of clinical trials that support its use for patients with spinal cord injuries (Szecsi and Schiller). There is evidence demonstrating improvement in muscle atrophy, aerobic fitness, and cardiovascular health (Johnston, et al). In this particular case, the patient has tolerated a trial with the RT300 FES system with improvement noted with interval sessions. Consistent with these findings, the requested FES system is likely to be more beneficial for treatment of the patients medical condition than standard therapy.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for Euflexxa injections to the right knee.An exhaustive review of the current medical literature pertaining to viscosupplementation reveals mixed results. Evidence from eight systematic reviews and six randomized controlled trials indicates that although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. Different studies have tried mixing hyaluronic acid with corticosteroids, platelet rich plasma, and other agents to make it more effective. The current evidence is limited, and guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate that the evidence is not conclusive. In light of the foregoing, viscosupplementation can only be recommended in individuals with a history of lasting benefit from prior injections, and in carefully selected cases where everything else has been tried, and the options are limited. In this case, the patient has a history of good lasting relief from viscosupplementation in January 2021. The injections relieved his pain and improved mobility. Therefore, Euflexxa injections to the right knee are medically necessary for 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 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 medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 46-year-old male enrollee has requested autologous chondrocyte implantation (ACI) for treatment of his right knee pain.  Findings:  Three physician reviewers found that the medical literature is insufficient to support the use of ACI in this setting. There is a lack of adequate clinical trials supporting ACI to repair articular cartilage defects of the knee. Knutsen and colleagues compared ACI with microfracture and determined that both had acceptable short-term results with no significant difference in macroscopic or histological results between the two treatment groups. Moreover, there is a lack of long-term, controlled randomized trials supporting ACI over other interventions in terms of safety and efficacy. Therefore, the requested ACI is not likely to be of greater benefit than other available modalities.
Appeal type: Experimental/Investigational
Decision: Overturned

A 19-year-old male enrollee has requested for an autologous bone marrow transplant for treatment of his neuromyelitis optica.   Findings:  Two physician reviewers found that therapies which are used for severe and aggressive MS have been tried without success, with resulting severe progression of disease. Bone marrow transplant has been used with success in other cases of severe and aggressive demyelinative disease. All standard therapies have been explored and exhausted.
Appeal type: Experimental/Investigational
Decision: Upheld

A 63-year-old female enrollee has requested coverage for the Bioness (NESS) L300 foot drop system for treatment of her multiple sclerosis and chronic regional pain syndrome. Findings:  Two physician reviewers found that the available literature does not present evidence of long term functional change beyond what would be expected with standard care for the lower extremity (Stein, et al. 2006 and Everart, et al.). All told, the NESS L300 device has not been shown to be advantageous over standard care for foot drop secondary to multiple sclerosis with associated complex regional pain syndrome.