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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for platelet-rich plasma (PRP) treatment. Findings:  The physician reviewer found that Results of numerous quality trials on the efficacy of PRP for treatment of chronic lateral epicondylitis have been highly variable and lack adequate data to support their use in lieu of standard therapies. Linnanmaki and colleagues found that PRP injections did not improve pain or function at one year follow-up in patients with lateral epicondylitis compared with patients who received a saline injection. In addition, de Vos and colleagues noted that PRP injections were not efficacious in the management of patients with chronic lateral elbow tendinopathy. Simental-Mendia and colleagues performed a systematic review and meta-analysis of randomized placebo-controlled clinical trials on the safety and efficacy of PRP injections in the treatment of patients with chronic lateral epicondylitis. The authors concluded that PRP injections have not been demonstrated to be superior to placebo for relieving pain and joint functionality in patients with chronic lateral epicondylitis. For this patient with bilateral lateral epicondylitis, the medical literature does not support an indication for the requested PRP injections. Given these findings, the requested PRP treatment is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Findings: Two of the three physician reviewers found the requested PRP treatment is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that The requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewer 1 is board certified in orthopedic surgery and is actively practicing. Physician reviewer 2 is board certified in orthopedic surgery and is actively practicing. Physician reviewer 3 is board certified in orthopedic surgery 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

A 48-year-old female enrollee requested authorization and coverage of the medication lamisil for the treatment of onychomycosis and subungal hyperkeratosis  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 medication is not medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

A 32-year-old female enrollee has requested a positron emission tomography with computed tomography (PET/CT) attenuation for evaluation of her appendiceal cancer.   Findings:  Two physician reviewers found that the patient has a very rare form of cancer that has no established guidelines. As the appendix is very close to the ascending colon, some providers may recommend application of colon cancer guidelines to guide the use of PET in cancer of the appendix. This may be especially the case when the diagnosis is adenocarcinoma and not a mucinous tumor. In this case, it was an adenocarcinoma with only a 5% focal mucinous component. There is limited peer reviewed medical literature on this topic, and there is no consensus as evidenced by the above references. However, the compelling justification for use of PET/CT imaging in this patient is that tumor was avid on prior PET/CT study. As the prior PET/CT was helpful in establishing this patients diagnosis it is likely to be a useful study in re-staging the tumor. For these reasons, the PET/CT scan performed on the date in question should be covered as it was more likely to provide useful data in the management of this patients condition.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 51-year-old woman with diabetes mellitus type II. She has been treated with several oral agents and Lantus insulin. Byetta was added to her regimen, resulting in maintenance of excellent control of her diabetes with an A1C of less than 6.5%. The patient has been able to discontinue Glucotrol and has experienced a 14-pound weight loss since starting Byetta. She would like to continue taking Byetta and therefore, has requested authorization for the drug. The Health Plan has denied the patients request on the basis that Byetta is not medically necessary for treatment of the patients condition.One of the goals in treating diabetes mellitus is weight loss. The submitted clinical information indicates the patient was able to achieve a 14-pound weight loss while on Byetta. Her prior treatment regimen actually resulted in significant counterproductive weight gain. Furthermore, available data suggests there is beta cell preservation with Byetta, which is in contrast to the ongoing loss that is experienced with Glucotrol and insulin. For these reasons, I have determined the requested medication is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 14-year-old male enrollee has requested for growth hormone therapy (Nutropin) for treatment of the enrollees growth failure. Findings:  The physician reviewer found that the FDA approval for GH use in idiopathic short stature is restricted to patients who are more than 2.25 standard deviations from the mean in terms of their height.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested Harvoni for 12 weeks for treatment of his hepatitis C.  Findings:  The physician reviewer found that there is a lack of support for the requested medication in this clinical setting.  An accurate assessment of fibrosis is vital in assessing the urgency for treatment.  The degree of hepatic fibrosis is one of the most robust prognostic factors used to predict disease progression and clinical outcomes.  In this patients case, a fibrosis score was not provided.  Fibrosis stage should be obtained before the medical necessity of the requested treatment can be established.  Therefore, Harvoni for 12 weeks is not medically indicated for the treatment of this patient.   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 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

The enrollees parent is requesting reimbursement for neuropsychological testing. The enrollee has persistent depressive disorder. She underwent psychotherapy and received a psychoeducational assessment for academic challenges, including difficulty with reading, letter and number recognition, and retrieval. The enrollees mother reported the enrollee had challenges with mood regulation, social navigation skills, attention and concentration skills, and planning and organization skills. Neuropsychological testing resulted in recommendations for medication consultation, cognitive-behavioral therapy, dialectical behavior therapy, social skills training, behavioral programs for sleep disruption and exercise, speech-language therapy, and educational remediation. The neuropsychological assessment also resulted in diagnoses of dysthymic disorder, intermittent major depressive episodes, social pragmatic communication disorder, and attention deficit hyperactivity disorder. Depending upon the age of the child, the childs level of tolerance and the numbers of tests, the assessment itself may require multiple days. In addition to conducting tests, a parent and child interview and feedback session is performed.Final Result: The reviewer determined that the requested service is medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in psychiatry and 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:The parent of 10-year-old male enrollee has requested authorization and coverage for social skills group speech therapy. Findings:  The physician reviewer found that a study reviewed social skills groups for people aged 6 to 21 with autism. The authors reported that there is some evidence that social skills groups can improve social competence for some children and adolescents with autism, however more research is needed to draw more robust conclusions, especially with respect to improvements in quality of life. Another systematic review noted that Social skills interventions presently appear modestly effective for youth with [autism spectrum disorder] ASD, but may not generalize to school settings or self-reported social behavior. In this case, the patients pragmatic skill delays are due to behaviors associated with an autism spectrum disorder and likely further complicated by ADHD. His scoring on standardized measures of less than 1.5 standard deviations below the mean does not support speech therapy treatment, which is typically reserved for individuals scoring two standard deviations below the mean. The Health Plans recommendation for ABA to address the patients social communications skills is medically reasonable and appropriate. Based on the documentation submitted for review, the request for social skills group speech therapy has not been established as medically necessary for treatment of the patients medical condition. Final Result: The reviewers 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: Physician reviewer is board certified in pediatrics with sub-specialty certification in developmental and behavioral 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: Medical Necessity
Decision: Upheld

A 58-year-old female enrollee has requested an MRI of the brain and spine for evaluation of her multiple sclerosis. Findings:  The physician reviewer found that the submitted documentation shows that the patients multiple sclerosis has been stable, with no evidence of a recent exacerbation.  The patient has not had any new or worsening neurological symptoms characteristic of multiple sclerosis. The use of an MRI in the evaluation of multiple sclerosis is widely accepted in the initial diagnosis of multiple sclerosis and to monitor response to therapeutic treatment. There is a lack of support in the peer-reviewed literature for the use of MRI for surveillance in patients who have stable multiple sclerosis symptoms. Per the Consortium of Multiple Sclerosis Centers, MRI of the brain is recommended for multiple sclerosis patients in order to evaluate an unexpected clinical worsening concerning for a secondary diagnosis, for reassessment of the original diagnosis and for reassessment before starting or modifying therapy. As this patient has no new neurological symptoms or physical findings to suggest an exacerbation of her multiple sclerosis, MRI of the brain and spine is not medically indicated.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Monovisc injection in the left knee. Findings: Per the medical literature, although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. 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 post-traumatic osteoarthritis of the left knee. The patient has tried and failed other conservative measures including physical therapy, bracing, and Voltaren gel, with the alternative being a total knee arthroplasty. Given the patients limited options and based on the current medical literature, the requested service is medically indicated. Therefore, Monovisc injection in the left knee is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested service 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 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 56-year-old woman who has a history of left shoulder and forearm pain in addition to neck and back pain secondary to degenerative disc disease. The patients treating physician has recommended the patient undergo an open MRI of the left arm, cervical spine and lumbar spine. The Health Plan has denied this request indicating the requested diagnostic procedures are not medically necessary for evaluation of the patients condition.Based upon the information provided, there is no medical justification for an open MRI of the arm, and cervical and lumbar spine at this time. There is no significant neurological deficit or concern for tumor documented in the records provided. It does not appear the patient has recently been evaluated by an orthopedist. The Health Plans recommendation that the patient be evaluated by an orthopedist is medically reasonable and appropriate. After a full evaluation of the patient the orthopedist can determine if imaging studies should be performed. Therefore, I have determined the requested diagnostic procedures are not medically necessary for evaluation of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 56-year-old female who has been diagnosed with bilateral knee osteoarthritis. On 1/18/19, the patient received a third right knee Euflexxa injection. Physical examination findings included tenderness over the right knee joint line and retropatellar regions of the right knee. On 3/29/19, the provider noted that previous viscosupplementation injections provided good results. On 4/16/19, the patient received a third left knee Euflexxa injection. Physical examination findings included tenderness over the left knee joint line and retropatellar region of the left knee. The patient has requested authorization and coverage for Euflexxa injections in both knees. The Health Plan denied the request and reported the requested services are not medically necessary for the treatment of this patient. At issue in this case is whether Euflexxa injections in both knees are medically necessary for the treatment of the patients medical condition. Review of the current medical literature pertaining to viscosupplementation reveals mixed results.  Although viscosupplementation may relieve knee pain in some patients with osteoarthritis, it is unknown which patients will benefit. Viscosupplementation can only be recommended in patients with a history of lasting benefit from prior injections and in carefully selected cases where the options are limited. The physician reviewer found that  viscosupplementation increased functional scores in patients with severe osteoarthritis of the knee, especially within three months of injection. In this case, the patient had an excellent response to prior viscosupplementation injections. Furthermore, her options are limited. The medical evidence supports the requested services in this clinical setting. Therefore, Euflexxa injections in both knees are medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for hydrocodone/acetaminophen (Norco) 10-325 mg, quantity 120, and carisoprodol (Soma), quantity 120. Findings:  The physician reviewer found that the step wise World Health Organization (WHO) ladder for pain relief is considered the reasonable approach to pain control in the palliative setting. Applying this guideline, not all non-opioid and narcotic treatment options have been utilized in this patients case. There is no documentation of the completion of behavior therapy despite much research to support its use. Furthermore, no objective treatment goals for pain and function are noted for the requested medications . The Centers for Disease Control and Prevention (CDC) also state that when opioids are started, providers should prescribe the lowest effective dosage. Finally, not all non-opioid and non-narcotic medications classes have been optimized or tried . For these reasons, the requested hydrocodone/acetaminophen (Norco) 10-325 mg, quantity 120, and carisoprodol (Soma), quantity 120 are not medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the requested medications 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 with sub-specialty certification in 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: Medical Necessity
Decision: Overturned

The parent of a 29-month-old female enrollee has requested speech therapy for treatment of the enrollees speech delay. Findings:  The physician reviewer found that speech therapy is indicated in patients with any delay greater than 25% (Feldman, et al.). Extensive review of the literature including a meta-analysis by Law, et al. noted a positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulty. Feldman, et al. note that treatment for language disorders is predicated primarily on the childs language profile and level of communication skills. Approximately one-half of children delayed at two years catch up to peers by three years of age. However, those children with mild to moderate disorders are more likely to resolve their delay compared to those with severe disorders. Children who participate in speech-language treatment show better improvement then those children who have no treatment (Feldman, et al.). Gallagher, et al. evaluated speech and language interventions for 24 preschool children with specific language impairment. The authors found statistically greater improvement with intensive direct speech and language therapy delivered by speech and language therapists over an eight-month period when compared to no intervention or nursery-based intervention. In this case, the requested speech therapy was and is medically necessary for this patient.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  The parent of an enrollee has requested residential treatment center services for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found that based on the documentation submitted for review, residential treatment center services were not medically necessary for treatment of the patients behavioral health conditions. The medical records submitted for review do not demonstrate that the patient had severe emotional problems or symptoms which required 24-hour supervision. In addition, she did not have evidence of suicidality or homicidality, self-harming behaviors, physical aggression, impairment in activities of daily living, or disruptive behavior. The patient did not exhibit severe anxiety, and she was able to manage her emotions well. The patient was able to have a home visit during which no behavioral problems were identified. There was no evidence that the patient would have resulted in worsening of her condition due to the less restrictive outpatient level of care. Multiple notes throughout the course of the admission noted that the patient was having a good day.  She was consistently compliant with medications with no side effects of the medications. She appeared to have a supportive family and was cooperative with care. Throughout the patients admission, the few medication management changes that were made were minor adjustments and could have been performed in an outpatient setting.  Given the above, the services at issue were not medically necessary for treatment of the patients medical condition.  Final Result: The reviewer determined that the services at issue were 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.