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

A 55-year-old female enrollee requested authorization and coverage of IDET for the treatment of chronic pain syndrome.  The enrollee has had several back surgeries in the past.  The health plan denied the enrollees request indicating that the requested treatment is experimental.Three physician reviewers performed an experimental/investigational Independent Medical Review.  Each of the three physician reviewers concluded that IDET is not likely to be more beneficial for treatment of the enrollees chronic pain syndrome than any available standard therapy.  Because all three physician reviewers concluded that the requested treatment is not likely to be more beneficial for treatment of the enrollees medical condition than any available standard therapy, the review organization upheld the health plans denial.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: A female enrollee has requested reimbursement for the blood test (tumor necrosis factor (TNF) antagonists) and testing for antibodies (substances in the blood that help with immunity) for evaluation of the enrollees Crohns disease. Findings:  The physician reviewer found that testing trough levels of infliximab during induction as well as maintenance has proven to be useful. In addition, infliximab levels and antibody levels also help in optimizing the infliximab doses and has strong correlations with the clinical presentation and laboratory results. Moreover, this testing can help predict a patients future response to therapy. Immunomonitoring is being increasingly used to optimize response rates in inflammatory bowel disease and has become the standard of care. All or most patients treated with infliximab have trough levels sampled either during the induction period or during a clinical relapse to determine whether they have adequate drug levels that may need to be adjusted or if they have antibodies requiring a change in the biologic therapy. Given this support, the blood test (TNF antagonists) and testing for antibodies (substances in the blood that help with immunity) performed on 4/26/16 was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: All three reviewers determined that the testing at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewer number one is board certified in pediatrics with sub-specialty certification in pediatric 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.Physician reviewer number two is board certified in pediatrics with sub-specialty certification in pediatric 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.Physician reviewer number three is board certified in pediatrics with sub-specialty certification in pediatric 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

A 62-year-old male enrollee has requested transforaminal epidural injections for the treatment of his chronic lumbar back pain and degenerative disc disease. Findings:  The physician reviewer found that the American College of Occupational and Environmental Medicine (ACOEM) guidelines note that injections are not indicated in chronic low back pain in the absence of radicular symptoms or for treatment of any chronic problems. Review of the submitted clinical evidence reveals no indication of radicular symptoms, sciatic symptoms or symptoms of facet pain. Furthermore, a thorough search of the relevant medical literature revealed no support for the use of injections for chronic, midline, and axial pain.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/ Case Summary:  The parent of the enrollee requested authorization and coverage for deep brain stimulation (DBS) surgery. The enrollee has a history of encephalomyelitis, left basal ganglia infarct, seizures, and right-sided dystonia. The neurosurgeon indicates the enrollee would be a good candidate for DBS surgery.  Treatment for dystonia includes Botox and Baclofen with variable outcomes. Due to the enrollee's lack of significant response to these treatments, deep brain stimulator (DBS) is a treatment option. The medical literature indicates children with functionally debilitating, medication-resistant secondary dystonia, without fixed skeletal deformities, can benefit most from this procedure.  Because of the variability and limited studies in pediatric dystonia, there are no current consensus treatment guidelines. However, patients that do respond to DBS exhibit significant improvement in quality of life regardless of the underlying cause.  The utilization of deep brain stimulation in children is relatively rare, but the procedure demonstrates a reduction in motor symptoms and disability in pediatric patients with dystonia.  Patients respond better to DBS than to medications and the procedure can have benefits for those who have proven refractory to Botox treatment.  Final Result: Three of the three reviewers determined that the requested services are likely to be more beneficial than any available standard therapy for treatment of the enrollees medical condition. Credentials/Qualifications: One reviewer is board certified in pediatric neurology and neurodevelopmental disabilities, two reviewers are board certified in neurosurgery and 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

Nature of Statutory Criteria/Case Summary:  An enrollee has requested a cervical epidural (nerve block), pic line with feeding tube, Fentanyl patch, morphine, Toradol and Percocet for treatment of her medical condition.  Findings:  The physician reviewer found that The American Society of Interventional Pain Physicians (ASIPP) guidelines recommend that a comprehensive assessment of a patient should be initiated prior to or in the maintenance of chronic opioid therapy of 90 days or longer. The standard of care requires a complete history, physical examination, and a comprehensive work up of the origin of the pain which may include various testing modalities. Urine toxicology screening is also required prior to starting opiates (Manchikanti, et al). Based upon the submitted records the patient has not been evaluated for her pain recently. While there is a record showing a recent visit with a social worker from the hospital, there is no record to indicate the patient was seen by her primary care provider or a pain management provider. The records also show she was scheduled for three pain management appointments but these appointments were canceled by the patient. There is no documentation as to urine toxicology screening, physical examination or pain management consultation. The patient has not undergone a comprehensive assessment in order to determine and identify appropriate pain medication therapy. For these reasons and per accepted standards of care, the requested therapies are not medically necessary for treatment of this patients medical condition.   Final Result: The reviewer determined that the requested therapies 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-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

 Nature of Statutory Criteria/Case Summary: An enrollee has requested 16 hours total of skilled nursing services per day, including eight hours of skilled nursing services previously mandated by independent medical review for treatment of her medical condition. Findings:  The physician reviewer found that the request for 16 hours total of skilled nursing services per day, including eight hours of skilled nursing services previously mandated by independent medical review has been established as medically necessary in this clinical setting. According to the documentation submitted for review, the patient presents with ALS and receives hospice care in the home setting. According to Newman and colleagues Continuous care most commonly is provided for two to three days; however, it can remain for a longer period of time if the acute medical crisis continues and the goal is for the patient to remain at home. The authors note that intensive home hospice services can be necessary to meet the goals of the patient. In this case, the patient is dependent for self-care, functional mobility, feeding and breathing. Tiirola and colleagues found that respiratory symptoms are a significant problem for ALS patients in hospice. Patient positioning is an important part of managing these symptoms as is care of the tracheostomy. In this case, there is sufficient support for the medical necessity for the requested services 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 physical medicine and rehabilitation 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 60-year-old male requested authorization and coverage of a referral to a dermatologist. The Health Plan denied the request indicating that the requested referral is not medically necessary for treatment of the enrollees skin lesions.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested referral is not medically necessary at this time.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for intravenous immunoglobulin (IVIG).Findings:  The physician reviewer found that this patient has been diagnosed as having CIDP, and has been treated once with IVIG with a report of improvement. She then subsequently worsened. This clinical picture is consistent with a sensorimotor neuropathy, and CIDP is one of the more common causes of asymmetric weakness of the upper and lower extremities. The EMG reports are the providers impression only, and none of the actual data is included for review. Clinically, it is likely that this patient has CIDP, but given the lack of appropriate laboratory testing for an immune related neuropathy, lack of spinal fluid analysis indicating elevated protein, and the lack of actual EMG tracings, the diagnosis is not fully confirmed. Given these findings, IVIG is medically necessary and should be approved for one treatment with follow-up with a neuromuscular specialist to determine if the patient has another etiology for CIDP. Final Result: The reviewer determined that a portion of the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned. Credentials/Qualifications: The reviewer is board certified in neurology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:   An enrollee has requested substance abuse residential treatment services for the treatment of his behavioral health conditions.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  Per the medical records, the patient was doing well in cognitive behavioral therapy and 12-step and the daily clinical record revealed that the patient was motivated for care, making good progress and had no new stressors.  He denied suicidal ideation and there was no evidence of behavioral dysregulation, an acute psychiatric syndrome or unresolved medical condition.  The record did not include an inventory of past treatment interventions such as community- or school-based services, family therapy, intensive outpatient programming or partial hospitalization with a supportive living environment.  Thus, the records do not demonstrate transition to a less restrictive setting would have been inadequate or unreasonable.  Considering the clinical presentation and patient history, substance abuse residential treatment services were not medically necessary for the treatment of this patient.   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 and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:   An enrollee has requested a positron emission tomography/computed tomography (PET/CT) for evaluation of his medical condition.  Findings:  Two physician reviewers found that in terms of follow-up for this patient, the provider suggested two possibilities that might explain the lesion, and the conclusion was that the lesion had overall benign features. Both lymphangiomas and duplication cysts are relatively rare lesions. In the lesser sac, one is more likely to find a pancreatic pseudocyst or a gastrointestinal stromal tumor (GIST). Significant pancreatic lesions can also be cystic. GIST tumors are the most frequent mesenchymal malignancy of the gastrointestinal tract, and on occasion, may also have cystic or otherwise benign features. PET/CT scans have been shown to be useful both in the evaluation of pancreatic neoplasia as well as the management of GIST tumors. If the lesion were found to be metabolically active, one would proceed with a more aggressive approach. Alternatively, if the lesion was not fluorodeoxyglucose (FDG) avid, simply obtaining a follow-up CT scan would be appropriate. This patient had an inconclusive CT scan, which means the tumor is suspicious. In this clinical setting, a PET/CT will help direct future evaluation and treatment of this patient. Thus, the requested PET/CT is likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.  Final Result: Two reviewers determined that the requested diagnostic procedure is likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications:  All three reviewers are board certified in diagnostic radiology and are actively practicing. 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: Overturned

A 39-year-old male enrollee has requested acupuncture, two times per week for eight weeks for treatment of his stated condition of severe neck and upper back pain.  Findings:  The physician reviewer found that this patient presents with a chronic pain condition for which surgical procedures were recommended by four different specialists six years ago. The patient previously underwent acupuncture, which benefitted his condition with frank symptom reduction, and for several years thereafter he did not need any additional care. The patients condition recently deteriorated and under the recommendation of his primary care provider, acupuncture was rendered again with symptom reduction. Based on the patients previous response to treatment, the records reviewed, and the peer reviewed medical literature, a modified treatment plan of six acupuncture sessions would be appropriate and beneficial to help the patient improve from the recent flare-up. Evidence of objective, significant and functional improvement is essential to establish the reasonableness and necessity of care and should be documented in future exams, if additional care beyond the six sessions herein recommended, is requested. Self management strategies like an independent exercise program (HEP), self-imposed restrictions, proper biomechanics and work modifications (if available and needed) are supported by peer review literature to avoid unnecessary passive care and to stimulate self reliance. In sum, after reviewing the medical reports and other documentation submitted for the treatment request, I find that a modified treatment plan of six sessions is supported as medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

A 50-year-old female enrollee has requested for a virtual colonoscopy for evaluation of her abdominal pain. Findings:  The physician reviewer found that the use of virtual colonoscopy is neither the standard of practice nor the community standard. If the patient is unable to tolerate the colonoscopy and the associated necessary sedation medications because of her allergy issues, then a barium enema is the next test that needs to be done.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 30-year-old female who has been diagnosed with chronic kidney disease as a result of lupus nephritis and anemia. The patients provider diagnosed the patient based on proteinuria over 2 grams. The patient is now anemic. The patients provider has recommended Procrit for treatment of the patients anemia. The Health Plan has denied authorization for the requested medication stating the patient does not meet Health Plan criteria for its use.The use of Procrit to treat the anemia of chronic renal failure is best documented to be successful when the glomerular filtration rate is low. Review of the relevant medical literature reveals the glomerular filtration rate is typically below 30, though sometimes anemia can improve with Procrit for glomerular filtration rates between 30 and 60. This patients glomerular filtration rate was greater than 60; thus, according to the usual indications for Procrit for anemia in chronic renal disease, this patient would not fit the approved criteria. Furthermore, it is unlikely that the presence of proteinuria as a marker of chronic kidney disease would be an adequate pathophysiologic reason for Procrit to be used. Therefore, I have determined that the requested medication is not medically necessary for treatment of the patients medical condition. Accordingly, the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a five-year-old male enrollee has requested a consultation with an orthopedic specialist for treatment of the enrollees mild to moderate bilateral foot pronation.  Findings:  The physician reviewer found that foot pronation involves turning the foot outward at the ankle, with preference for walking on the inner border of the foot. While most of these conditions resolve spontaneously, a small percentage will persist unless treated.  It is important to initiate treatment early to optimize treatment. While exercises and specialized orthotics may be helpful for very young children, as the child ages, the likelihood that these will help decreases.  At this point, a referral to an orthopedic surgeon would be appropriate to determine the nature of the problem and the most successful plan of care. In this patients case, the functional positioning of his feet negatively impacts his mobility. He has participated in physical therapy, yet continues to have this problem.  All told, the requested consultation with an orthopedic specialist is medically indicated in this patients case.
Appeal type: Experimental/Investigational
Decision: Upheld

A 34-year-old female enrollee has requested Botox injections for treatment of her headaches and temporomandibular joint (TMJ) dysfunction. Findings:  Two physician reviewers found that although the medical literature reveals that the use of Botox to treat symptoms similar to the types of symptoms this patient has suffered from is encouraging, the data is not yet conclusive. Additionally, the use of Botox is generally reserved until standard therapies have been exhausted. Based on the medical records submitted, it does not appear this patient has attempted other well-accepted conservative therapies and treatments for her facial pain. Should she try and fail these types of therapies, and if trigger points can be identified within her masticatory muscles, she may then be an appropriate candidate for Botox injection therapy. However, based on the documentation provided, the superiority of Botox compared to standard therapies in this setting is not established.