Persius/imr-appeals huggingface dataset:
Appeal type: Urgent Care
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee requested air and ground ambulance transportation services on an emergent basis. Findings: The physician reviewer found that the medical records indicate that the patient had an open fracture of the arm with intact radial artery and a damaged ulnar nerve. The vascular status to the arm was documented to be intact. The wound was cleaned and splinted. In this scenario, a prudent layperson would reasonably believe that air transport to the closest facility capable of treating the patient was appropriate. Based upon the information provided, transport arranged through the health plan to a more local hospital was declined over transport to a facility involving significantly longer air travel.  As such, a prudent layperson would not reasonably believe that air and ground ambulance transportation services were required at the time they were provided.  Final Result: The reviewer determined that the services at issue did not meet prudent layperson criteria for emergency care. 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 medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a five-year-old male with a history of speech delay described as both expressive and receptive. The patient was evaluated by a speech therapist and subsequently treated for delayed speech for approximately two years. A formal speech evaluation including standardized tests or goals is unavailable. A neurologist examined the patient and documented the patients history of speech delay. No other neurologic abnormalities were documented. At issue is whether speech therapy is medically necessary for treatment of the patients condition.The information submitted provides insufficient documentation of specific deficits of speech. It does not appear that standardized testing was performed to document the severity of the patients speech delay. Furthermore, there is no evidence that the patients speech delay is related to a neurologic condition. It was well documented by the patients neurologist that no other neurologic findings were present upon exam. In cases of speech delay without neurologic findings, speech therapy is not medically indicated. Therefore, I have determined that the requested therapy is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:   An enrollee has requested facet ablation and epidural injections for treatment of her low back pain.  Findings:  The physician reviewer found that facet ablation and epidural injections are not medically necessary for treatment of this patients medical condition. The peer-reviewed medical literature does not support a series of epidural steroid injection in treating the patients medical condition. Two authors performed a literature review to determine the current evidence to support guidelines for frequency and timing of epidural steroid injections and to help determine what sort of response should occur to repeat an injection, and to outline specific research needs in these areas. The authors concluded There does not appear to be any evidence to support the current common practice of a series of injections. Moreover, the medical literature indicated that there was moderate evidence for interlaminar epidurals in the cervical spine and limited evidence in the lumbar spine for long-term relief. Given that the patient did not experience long-term relief, or demonstrate reduced use of medications and adjunctive therapy (physical therapy, heat and ice) with the previous epidural steroid injection, a repeat epidural steroid is not medically necessary. In addition, the patient had a medial branch block, and there was no follow-up note showing the patient had a positive diagnostic block. Facet radiofrequency ablation is indicated in patients with positive diagnostic blocks. For the reasons provided, the request for facet ablation and epidural injections is not medically necessary for treatment of the patients medical condition. 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 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: Upheld

A 55-year-old female enrollee requested a gene test for medical evaluation of her thyroid nodule.  Findings:  Three physician reviewers found that the gene expression classifier (GEC) test is a relatively new method of obtaining additional information on the malignancy potential of thyroid nodules.  GEC is a tool that is best used when an indeterminate result is obtained in the cytology study and the provider is not able to determine whether surgery would be beneficial.  A benign result will favor continued observation and no surgery.  However, in this case, there is no documentation of a prior cytologic study with indeterminate result.  The report of this biopsy indicates that the genetic testing was the sole study performed in the specimen.  Thus, the gene test was not likely to be of greater benefit than other modalities for evaluating this patient.
Appeal type: Urgent Care
Decision: Overturned

A 62-year-old female enrollee has requested emergency services for the treatment of her medical emergency. Findings:  The physician reviewer found that this patient had a known history of blood clots in her portal vein. Upon further evaluation, she was found to have an acute blood clot in her heart for which further testing was necessary. The patients symptoms met prudent layperson criteria for emergency care. A prudent layperson with an average knowledge of medicine and health would reasonably expect the absence of emergency care to jeopardize their health.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Dexilant for treatment of his gastroesophageal reflux disease (GERD).  The physician reviewer found that this patient reports that his GERD symptoms have been treated for several years with Dexilant. However, his records do not include pathology from an endoscopy that shows GERD or Barrets esophagus. In addition, the records do not indicate that he has been on Dexilant for the past year or that he has tried and failed other proton pump inhibitors. Absent this documentation, the patient should be treated with standard proton pump inhibitors to determine whether he can adequately control his symptoms before being treated with Dexilant. Accordingly, the requested Dexilant 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 gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A female enrollee requested Orthovisc (hyaluronate) injections for medical treatment of the enrollees medical condition.  Findings:  Two physician reviewers found that the peer-reviewed literature indicates that the injections may provide short-term relief.  However, the literature noted that treatments are not available to halt the degeneration process once it has begun.  In this patients case, continuation of the injections will not alter the need for surgical intervention.  All told, the requested Orthovisc (hyaluronate) injections are not likely to be superior over other modalities.
Appeal type: Experimental/Investigational
Decision: Upheld

An enrollee has requested authorization and coverage for a ReWalk personal system. The published evidence indicates that powered exoskeletal devices aimed at enabling upright ambulation in patients with paraplegia are not an efficient, reliable or practical means of mobility for this patient population. Further, there are multiple risks associated with the use of these devices as mobility devices outside of controlled environments including falls. There is a paucity of proven health benefits with the use of an externally powered exoskeleton to passively move a patients lower limbs. The current standard of care for achieving appropriate levels of cardiovascular and musculoskeletal exercise in the setting of this patients condition include regular physical activity using volitionally active musculature such as propulsion of a manual wheelchair, wheelchair sports, and other adaptive sports and exercise activities. For these reasons, the requested ReWalk personal system 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 equipment is 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 reviewer 1 is board certified in physical medicine and rehabilitation with subspecialty certification in neuromuscular medicine and is actively practicing. Physician reviewer 2 is board certified in physical medicine and rehabilitation with subspecialty certification in sports medicine and is actively practicing. Physician reviewer 3 is board certified in physical medicine and rehabilitation and is actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollees parent has requested reimbursement for Genomind Professional PGx Express genetic testing. In the records provided for review, this patient presents with a history of behavioral issues and learning disabilities. The patient underwent evaluation with Genomind Professional PGx Express genetic testing. Researchers stated that, Significant advances have been made in the application of pharmacogenomic testing for the treatment of patients with psychiatric disorders. Over the past decade, a number of studies have evaluated the utility of pharmacogenomic testing in pediatric patients with psychiatric disorders. However, the authors concluded that, more research is needed to understand the contributions of pharmacogenomics testing to the clinical treatment of children and adolescents. At present, there is inadequate evidence to support the use of pharmacogenomics in the clinical care of young patients with psychiatric disorders such as attention-deficit/hyperactivity disorder (ADHD), depression, and anxiety. All told, the Genomind Professional PGx Express genetic testing was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Findings:  Two of the three physician reviewers found the Genomind Professional PGx Express genetic testing was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the services at issue were 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: Physician reviewer 1 is board certified in pediatrics with subspecialty certifications in clinical genetics and clinical biochemical genetics and is actively practicing. Physician reviewer 2 is board certified in neurodevelopmental disabilities and subspecialty certification in neurology with special qualification in child neurology and is actively practicing. Physician reviewer 3 is board certified in clinical genetics and genomics and is 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 Harvoni once daily for 12 weeks.Findings:  The physician reviewer found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. The guidelines recommend that all patients should be treated, regardless of fibrosis stage. The guidelines do not restrict provision of hepatitis C therapy to specialists except in certain complex cases, in which referral to a specialist center is recommended and this case does not meet guideline criteria for specialist referral. The guidelines recommend that non-cirrhotic treatment-naive genotype 1 patients should be treated with Harvoni for 12 weeks. These recommendations are based on multiple randomized clinical trials, and the medication is U.S. Food and Drug Administration (FDA) approved for all patients with chronic hepatitis C genotype 1 regardless of fibrosis stage. The AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  The parent of an enrollee has requested residential treatment center level of care services for treatment of the enrollees behavioral health condition. The physician reviewer found that the residential treatment center level of care services were not and are not medically necessary for treatment of the patients medical condition. Based on the documentation submitted for review, this patient does not meet the criteria for admission to substance abuse residential treatment level of care and the services in dispute could have been provided at a lower level of care. There was no documentation of serious mental illness that would have complicated substance abuse treatment at a lower level of care. He also had no pre-existing medical problems that could have caused withdrawal complications and he had no past history of serious withdrawal complications. He was not at imminent risk of harm to self or others due to mental illness or substance abuse. He had access to safe supportive environments that would have allowed treatment at a lower level of care. Based on the medical literature cited above and the documentation submitted for review, the services at issue were not and are not medically necessary for treatment of the patients medical condition.  Final Result: The reviewer determined that the services at issue were not and 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 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: Overturned

A 60-year-old male enrollee has requested for the medication Epogen for treatment of his myelodysplasia.   Findings:  The physician reviewer found that Epogen is reasonable and necessary for treatment of his myelodysplasia syndrome. The records submitted establish that the patient meets accepted criteria for treatment with Epogen. It is not necessary to continue to monitor EPO levels. EPO levels are helpful as a baseline to determine the likelihood of a response.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: There is support in the documentation for the medical necessity for a portion of the requested services. According to the submitted records, the patient has a diagnosis of borderline personality disorder and DBT is the gold standard for treatment of this condition. DBT is evidenced-based treatment, which was initially designed for adults. However, this model has been adapted for treatment of adolescents who are diagnosed with borderline personality disorder. The medical literature recommends a length of treatment from 24 weeks to 16 weeks for adolescents in order to increase the likelihood of commitment. Family therapy is also included in the adolescent DBT model. There is support for DBT for adolescents diagnosed with borderline personality disorder. In this case, the patient is likely to benefit from the adolescent DBT model. For these reasons, a portion of the requested services is medically necessary. Specifically, weekly individual therapy sessions through an intensive outpatient dialectical behavior therapy program for 16 weeks is medically necessary. Given these findings, a portion of the requested services is medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that a portion of the requested services 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 psychiatry with expertise 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: Experimental/Investigational
Decision: Upheld

An enrollee has requested reimbursement for the Oncotype DX-Prostate Cancer Assay. Tissue-based molecular biomarkers including the Oncotype DX-Prostate Cancer Assay may improve the accuracy of prognosis when added to standard clinical parameters. Current data suggests that the Oncotype DX-Prostate Cancer Assay might be helpful for patients with low Gleason score and high volume or those with high Gleason score and low volume. However, these genomic assays are only clinically useful when the results, considered as a whole with routine clinical factors, are likely to affect a clinical decision. This patient had low Gleason score and low volume disease. There is a lack of peer-reviewed medical literature supporting a role for the Oncotype DX-Prostate Cancer Assay for patients with low Gleason score and low volume disease. Therefore, the Oncotype DX-Prostate Cancer Assay was not likely to be more beneficial for evaluation of the patients medical Final Result: The reviewers determined that 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: Physician reviewers 1, 2, and 3 are board certified in urology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 38-year-old male enrollee has requested for hemorrhoid removal surgery for treatment of her hemorrhoids.  Findings:  The physician reviewer found that Johannsson and colleagues found that many patients with grades III to IV hemorrhoidal disease have concomitant functional bowel symptoms, possibly associated with irritable bowel syndrome, which need to be taken into consideration when selecting treatment. Conservative therapy is the first-line of intervention for hemorrhoids and only if this fails or the patient experiences complications should second-line therapy, injection or banding be performed. A hemorrhoidectomy is reserved for Grade 4 hemorrhoids that cannot be treated by second-line therapy. In this case, the documents and photographs do not demonstrate a clinical indication to proceed with an operative intervention.
Appeal type: Medical Necessity
Decision: Upheld

A 21-year-old male enrollee has requested coverage for past adult substance abuse subacute/residential treatment center rehabilitation services for treatment of his polysubstance dependence and major depressive disorder. Findings:  The physician reviewer found that this patient presented with prominent addictive influence with anxiety and affective symptomatologies as well.  The American Psychiatric Association (APA) Clinical Practice Guideline on substance use stated [r]esidential treatment is indicated primarily for individuals who do not meet clinical criteria for hospitalization but whose lives and social interactions have come to focus exclusively on substance use and who currently lack sufficient motivation and/or substance-free social supports to remain abstinent in an ambulatory setting. In this particular case, the medical documentation provided fails to demonstrate the need for comprehensive treatment encompassing all elements of the bio-psycho-social model in a 24-hour supervised setting. Based upon the documentation provided, the patient posed no imminent danger to self or others, expressed motivation for care, possessed family support, and had not pursued less restrictive interventions, such as community programming, intensive outpatient or partial hospitalization, any of which would have been medically appropriate interventions in this setting. Accordingly, the services at issue were not medically necessary for treatment of the patients medical condition. The patient could have been appropriately treated in a less intensive level of care including community programming, intensive outpatient or partial hospitalization.
Appeal type: Medical Necessity
Decision: Upheld

The mother of an 18-year-old female enrollee requested authorization and coverage of continued residential treatment services for the treatment of the enrollees medical condition. The Health Plan denied the request indicating that the requested services 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 upheld the Health Plans denial on the basis that the requested services are not medically necessary.