Persius/imr-appeals huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Upheld

A 49-year-old male enrollee requested spinal surgery (implantation of total disc prosthesis in segments L2-3 and L5-S1) for medical treatment of his vertical segment instability at L5-S1 and L2-3 with stenosis at L2-3.   Findings:  Three physician reviewers found that currently, there is a paucity of peer-reviewed medical data demonstrating superior health outcomes with artificial disc replacement versus conventional interventions. Spinal fusion for patients with kyphosis and nonunion has been shown to be safe and effective. In addition, decompression for spinal stenosis is reasonable and appropriate. In the absence of clinical data supporting the spinal surgery (implantation of total disc prosthesis in segments L2-3 and L5-S1,) the services were not likely to have been more beneficial than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned

The parent of an 8-year-old male enrollee has requested 24-hour, video monitored, in-home electroencephalogram (EEG)for evaluation of the enrollees seizures.  Findings:  The physician reviewer found that the submitted documentation demonstrates the medical necessity of the 24-hour, video monitored EEG. The patient has a diagnosis of autism with concerns for non-convulsive seizure disorder. According to Filipek and colleagues, EEG evaluation is recommended if concerns and behaviors are noted in autistic children. Video EEG provides input to EEG findings and behaviors noted. In addition, Gabis and colleagues noted a higher incidence of epileptiform EEG abnormalities in autistic children with a history of regression compared to autistic children with clinical epilepsy. However, the medical literature lacks a standard consensus as to whether in-home or in-hospital video EEG monitoring is preferred in this setting. A diagnosis of autism does not preclude performance of video EEG monitoring in a hospital setting. Studies have noted that for patients requiring sedation, medications exist that are safe and do not cause EEG drug effect and which have a high success rate (Mehta, et al.). All told, 24-hour video monitored EEG is medically necessary in this case, however it is not medically necessary to perform the testing in the home setting.
Appeal type: Experimental/Investigational
Decision: Upheld

A 41-year-old male enrollee has requested  for Avastin for treatment of his non-small cell lung cancer. Findings:  Three physician reviewers found that Avastin is one of a new class of drugs that inhibits in some way the vascular endothelial growth factor (VEGF). It has been approved for use with chemotherapy in metastatic colon cancer. Avastin has also been approved for use as primary therapy with carboplatin and Taxol in metastatic, non-squamous non-small cell lung carcinoma based on one large study.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested magnetic resonance imaging (MRI) of the knee for evaluation of her right knee pain.  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the requested services. The documentation submitted for review does not demonstrate physical examination findings of joint looseness or tendon impingement. In addition, there is no documentation demonstrating the patient has tried and failed a course of physical therapy. Further, the medical records also do not indicate a trial of anti-inflammatory medication or acetaminophen for three or more weeks, which is standard of care treatment prior to MRI study. The patient should begin a course of conservative treatment, prior to an MRI being considered. Based on the medical literature and clinical documentation provided, the request for MRI of the knee is not medically necessary for evaluation of the patients medical condition. Final Result: The reviewer determined that the requested services are 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 with sub-specialty certification in interventional 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for advanced lipoprotein testing. Findings:  The physician reviewer found that American College of Cardiology (ACC) and American Heart Association (AHA) guidelines for the management of cardiac risk and dyslipidemia do not recommend routine performance of specialized tests in the context of assessing coronary risk including lipoprotein-associated phosholipase A2 (Lp-PLA2), sub-classifications of low-density lipoprotein (LDL), high-density lipoprotein (HDL) subclasses, lipoprotein(a), C-reactive protein (CRP), high sensitivity CRP, insulin, fibrinogen, genetic testing, and homocysteine.  Treatment changes or additions based on the results of screening with these specialized tests has not been shown to improve cardiac outcomes over those achievable by treatment based on standard risk factor profiling and basic lipid analysis. While results from of some of these specialized tests may be abnormal and considered independent risk markers for coronary disease, there is a lack of data in controlled trials demonstrating outcome benefits from treating routinely obtained abnormal results. Therefore, advanced lipoprotein testing was not likely to have been more beneficial for evaluation of the patients condition than any available standard therapy.Findings:  Two of the three physician reviewers found the advanced lipoprotein testing at issue was not likely to have been more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the service at issue was not likely to have been 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 internal medicine with sub-specialty certifications in cardiovascular disease and in adult congenital heart disease and is actively practicing. Physician reviewer 2 is board certified in internal medicine with sub-specialty certifications in cardiovascular disease and in clinical cardiac electrophysiology and is actively practicing. Physician reviewer 3 is board certified in internal medicine with sub-specialty certification in cardiovascular disease 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: Upheld

The patient is a 51-year-old female with chronic low lumbar pain from degenerative disc disease. The patients medical history indicates mixed physical and psychological features such as sleep disturbance, appetite disturbance, weight changes, energy disturbance, loss of lipids, and depression. The patient has also undergone two inpatient detoxification programs in 2003 for dependence to high doses of OxyContin. The patients current medication regimen includes: Duragesic 50mg every 48 hours; Ambien; phenobarbital; Lorazepam; propoxyphene; clonazepam; Baclofen; Wellbutrin XL; Seroquel; and Protonix.The patients physician notes increased drowsiness with increased Duragesic, grand mal seizures related to Methadone, and agitation for oxycodone. The patients physician is requesting authorization for Actiq for breakthrough pain on the basis that Actiq is the only narcotic the patient is able to tolerate.The patients complicated medical history with physical and psychological problems makes adding a short-acting narcotic medication to her current regimen a potential for more complications such as narcotic dependence and recurrent seizures. The patient is currently on an overlapping regimen of medications including narcotics, benzodiazepines, barbiturate, anti-psychotic medication, sleep agent, and anti-depressant. Adding Actiq to the above regimen will most likely lead to further complications with potentially negative consequences.Based upon the information set forth above, I have determined the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

A 49-year-old male enrollee has requested a PET/CT scan for an evaluation of his pelvic mass. Findings:  The physician reviewer found that this patient has multiple findings on recent CT studies of the abdomen and pelvis. It is uncertain if these findings are benign or malignant and further imaging of the abdomen and pelvis with MRI would be the next appropriate imaging study. MRI can help determine if the liver lesions are benign or malignant, evaluate the right renal fossa for a mass and further evaluate the pelvic mass. The PET/CT scan that was requested is not medically necessary at this time, as there is no known malignancy. Tissue biopsy is usually obtained prior to PET/CT scan. PET/CT scans are used for staging and restaging purposes and not for the initial diagnosis of cancer.
Appeal type: Medical Necessity
Decision: Overturned

An 18-year-old male enrollee has requested residential treatment services for treatment of his behavioral health conditions. Findings:  The physician reviewer found that this patient did well in the context of a structured setting, learning how to communicate with his parents while they learned how to effectively set boundaries.  He eventually learned to accept the boundaries and show respect.  However, he continued to struggle with avoiding blame and accepting responsibility.  In this patients case, residential treatment services provided from the time period specified were medically necessary.  During this time, the patient was still demonstrating anger, bargaining, and making threats when confronted with unpleasant situations.  However, he was able to contain his impulses and show respect for authority and his family relations were on the mend.  All told, the records support the medical necessity of residential treatment services provided from the time period specified, but not thereafter.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for rifaximin (Xifaxan). Findings:  The physician reviewer found that the use of Xifaxan is supported by current medical literature for both pouchitis and prophylaxis of hepatic encephalopathy. A meta-analysis of nine studies, including three randomized controlled trials, has demonstrated that antibiotic use is associated with a significant improvement in pouchitis compared to placebo or other treatment. Antibiotic-dependent pouchitis often requires chronic antibiotic therapy. In a study of 51 patients with antibiotic-dependent pouchitis, Xifaxan was used as long-term maintenance therapy after proctocolectomy with ileo-anal pouch. One study in 16 patients with antibiotic- and probiotic-refractory pouchitis demonstrated 81% of patients achieved remission with Xifaxan. Based on current medical literature, Xifaxan is effective for treatment of pouchitis. In this case, the patient has failed the alternatives ciprofloxacin and metronidazole multiple times. Xifaxan can also be used for prophylaxis of hepatic encephalopathy in this case, and its use is supported by studies demonstrating the efficacy of Xifaxan without concurrent use of lactulose. The formulary alternative lactulose is effective for hepatic encephalopathy prophylaxis, but is not useful for the treatment of pouchitis. For these reasons, the request for Xifaxan is supported as medically necessary for the treatment of this patients pouchitis and for hepatic encephalopathy prophylaxis. 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for strabismus surgery (CPT codes 67311 and 67312); and bilateral upper eyelid blepharoplasty (CPT code 15823) and right upper eyelid retraction repair (CPT 67911) for treatment of the enrollees dermatochalasis and right upper eye lid retraction. Findings:  The physician reviewer found that Thyroid eye disease, also known as Graves ophthalmopathy, can affect multiple aspects including the orbit, the eyelids and the muscles which can require surgical repair. In this case, the patient underwent orbital decompression as well as lower eyelid repair. Based on the clinical documentation provided for review, the patient has upper eyelid retraction as well as diplopia both of which are medically necessary to repair by performing eyelid retraction repair and strabismus surgery. However, based on the clinical documentation and photographs provided, the dermatochalasis and fat prolapse of the upper lids does not interfere with the patients vision and no evidence such as visual fields were provided to support the medically necessity of upper eyelid blepharoplasty. Therefore, strabismus surgery (CPT codes 67311 and 67312) and right upper eyelid retraction repair (CPT 67911) have been established as medically necessary. However, bilateral upper eyelid blepharoplasty (CPT code 15823) is not medically necessary. Final Result: The reviewer determined that a portion of the requested services are medically necessary for treatment of your medical condition.  Credentials/Qualifications: The reviewer is board certified in ophthalmology 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 62-year-old female enrollee requested authorization and coverage of continued physical therapy. The Health Plan denied the request indicating that the requested therapy is not medically necessary for treatment of the enrollees back pain.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: Medical Necessity
Decision: Overturned

A 29-year-old male enrollee has requested continued care with a pediatric cardiologist specialist (in lieu of an adult cardiologist) for treatment of his medical condition status post open heart surgery after birth.  Findings:  The physician reviewer found that this type of surgery was replaced more than 20 years ago with a superior procedure and therefore is rarely used. Patients who have undergone the Senning procedure can be stable for years, but are at risk for significant problems as adults including arrhythmias and right ventricular failure. Some patients may require arrhythmia treatment including pacemakers and radiofrequency ablation. In addition, some patients may require transplants when the right ventricle fails. All told, these patients require continuing care by a specialist in congenital heart disease as provided by a pediatric cardiologist. Adult cardiologists generally do not receive adequate training in complex congenital heart disease. It is common practice for congenital heart disease patients to continue to be cared for by their pediatric cardiologist in the absence of an adequately trained adult congenital cardiologist. For these reasons, the requested services have been demonstrated to be medically necessary in the management of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 59-year-old male enrollee has requested eye movement desensitization and reprocessing (EMDR) treatment for treatment of his behavioral health condition. Findings:  The physician reviewer found the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested services. EMDR is a therapy in which patients generate exposure to trauma via imagery while performing horizontal saccadic eye movements. A skilled therapist assists the patient in decompressing the anxiety burden stemming from the traumatic image or memory. EMDR is not recommended for the treatment of major depressive disorder, but it is a well-accepted treatment for posttraumatic stress disorder (PTSD). The records provided do not substantiate a clinical diagnosis of PTSD. As such, an independent diagnostic PTSD evaluation by a mental health professional specializing in the disorder is recommended.  In addition, if PTSD was diagnosed, EMDR would not be medically necessary unless the patient had a contraindication to, the inability to access, or had failed other evidence based treatments for PTSD, as EMDR has not been shown to have significant advantage over other first-line trauma-focused therapies such as prolonged exposure and cognitive processing therapy, or stress inoculation training. Based on the medical literature cited above and the documentation submitted for review, the requested services are not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Parents of a 11-year-old male enrollee requested authorization and coverage of occupational therapy for 16 weeks for the treatment of significant delays in fine motor/visual motor skills, motor co-ordination balance and equilibrium reactions. The Health Plan denied the enrollees request indicating that the requested treatment is not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer upheld the health plans denial on the basis that the requested therapy is not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for surgeries to remove excess skin on the enrollees eyelids. The submitted documentation fails to demonstrate the medical necessity of the requested services. The records document evidence of bilateral upper eyelid dermatochalasis. The patient complains of difficulty with her vision due to her excess upper eyelid tissue.  However, the degree of impairment directly related to the excess upper eyelid tissue and possible eyelid ptosis has not been adequately documented. A visual field analysis with taping and untaping of the eyelids has not been provided. The exact degree of ptosis of the upper eyelids cannot be adequately judged by the photographs provided. Therefore, the requested surgeries to remove excess skin on the patients eyelids are not medically necessary. 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 plastic 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the occipital nerve block for treatment of the enrollees intractable migraine headaches. Findings:  2/3 of the physician reviewers found that Occipital nerve blocks are not supported for the treatment of migraine or other type headaches. There was a lack of long-term improvement of headache of chronic migraine type with use of occipital nerve blocks. Greater occipital nerve blocks do not reduce the frequency of moderate to severe migraine days in patients with episodic or chronic migraine compared to placebo. No long-term improvement of headache of chronic migraine type with use of occipital nerve block. For these reasons, the occipital nerve block provided was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: 2/3 of the reviewers determined that the service at issue was 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 number one is board certified in internal medicine and 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.Physician reviewer number two is board certified in internal medicine and 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.Physician reviewer number three is board certified in internal medicine and neurology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 5-year-old male enrollee has requested applied behavioral analysis (ABA) therapy for treatment of the enrollees autism and severely delayed receptive and expressive language skills. Findings:  The physician reviewer found that the submitted documentation establishes the medical necessity of the requested therapy.  Applied behavioral analysis has been shown to be beneficial in the treatment of behaviors associated with autism spectrum disorder (Warren et al). Warren and colleagues reviewed 34 studies of early intervention in autism. The authors concluded that studies of Lovaas-based approaches and early intensive behavioral intervention variants and the Early Start Denver Model resulted in some improvement in cognitive performance, language skills, and adaptive behavior skills (Warren et al). Granpeesheh and colleagues studied 245 children with autism who were receiving behavioral intervention services and found that increases in treatment intensity led to continued increases in treatment gain. The rate of learning was much higher for those children receiving high intensity treatment (40 hours/week) (Granpeesheh et al). In addition, ABA behavior therapy is often provided at multiple settings including home and school (Hagopian and Boelter). For the reasons provided above, the requested therapy ABA therapy at the frequency of 40 hours a week including 15-20 hours in school and 15-20 hours at home is medically necessary for treatment of the patients medical condition.