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

Nature of Statutory Criteria/Case Summary:  The parent of an enrollee has requested speech therapy at the frequency of 3-4 times per month for treatment of the enrollees autism spectrum disorder and reduced receptive, expressive and pragmatic language skills.  The physician reviewer found that review of the submitted documentation and medical literature demonstrates the medical necessity of the requested services. Bitterman and colleagues examined the experiences of preschoolers with autism spectrum disorders (ASDs). The authors found that 86% of preschoolers with ASDs were receiving direct speech therapy in the preschool years. In addition, according to Myers and colleagues People with ASDs have deficits in social communication, and treatment by a speech-language pathologist usually is appropriate. Most children with ASDs can develop useful speech, and chronologic age, lack of typical prerequisite skills, failure to benefit from previous language intervention, and lack of discrepancy between language and IQ scores should not exclude a child from receiving speech-language services. This patient presents with considerable language delays. The speech therapy evaluation documented his speech skills were at the 6-9 month level. The patient was recommended for speech therapy at the frequency of 3-4 sessions per month. Initially, his speech therapy sessions did not go well as he was hyperkinetic and not engaged in therapy and as a result speech therapy sessions were decreased. However, subsequent speech therapy sessions went much better as a high chair was utilized which allowed the patient to stay more focused during activities. In this case, speech therapy at the frequency of 3-4 sessions per month is medically necessary and appropriate in this clinical setting. 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 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 59-year-old female enrollee has requested maxillofacial prosthetics for the treatment of her hemifacial spasm. Findings:  The physician reviewer found that hemifacial spasm is a neuromuscular disorder characterized by frequent involuntary contractions (spasms) of the muscles on one side of the face. Most often, hemifacial spasm is caused by a blood vessel pressing on the facial nerve at the place where it exits the brainstem. Known treatments for this condition include surgery and medication including Botox. Treatment of this condition with oral splints is not a widely accepted form of treatment and there is a lack of studies in the literature to support the use of oral splints for this condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 59-year-old female enrollee has requested hyaluronan (Euflexxa) injections for the treatment of her bilateral knee pain. Findings:  Two physician reviewers found that it is unlikely that simple introduction of aggrecan into the joint space will be incorporated into the complex structure of joint cartilage. There may be a short-term improvement in the viscoelastic properties of the synovial fluid until the aggrecan dissipates or breaks down. There is insufficient evidence that the hyaluronan injection will substantially alter prognosis or treatment. There are appropriate standard therapies available in this setting including non-steroidal anti-inflammatories (other than those already tried by the patient), a swim exercise program and the use of a cane or crutch to be used in the hand opposite the symptomatic knee. Hyaluronan is not likely to provide significant or lasting pain relief in this setting.
Appeal type: Medical Necessity
Decision: Upheld

A 57-year-old female enrollee has requested Nicotrol Inhalers for treatment of her chronic obstructive pulmonary disease (COPD) and tobacco use disorder. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services. The patient has a history of tobacco use disorder and was smoking 1-2 packs per day prior to her most recent cessation. Based on the medical literature, smoking cessation is most successful when patients are enrolled in a smoking cessation program where both pharmacologic and behavioral therapies are used. Additionally, prolonged continuous treatment beyond 12 weeks has not shown to be any more effective. At this time, there is a lack of evidence supporting the continued use of Nicotrol Inhaler beyond the 12 weeks already received. For the reasons set forth above, the Nicotrol Inhaler is not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Tysabri. The American Academy of Neurology practice guideline for adults with multiple sclerosis (MS) note that multiple studies have shown the benefits of disease-modifying therapies (DMTs) in reducing relapses of MS. The guidelines recommend that clinicians prescribe alemtuzumab, fingolimod, or natalizumab (brand name Tysabri) for people with highly active MS. Butzkueven and colleagues report that a ten-year interim analysis supports the robust real-world effectiveness and well-established safety profile of natalizumab in the treatment of relapsing-remitting MS. In this case, the patient has a diagnosis of relapsing-remitting MS. Given that current medical literature supports the use of natalizumab for the treatment of active MS, and as the patient reports good response on Tysabri without side effects, the requested medication is medically indicated. Therefore, Tysabri is medically necessary for the treatment of this patient.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 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 patient is a 36-year-old female who has a chronic condition of lower back pain with degenerative changes noted on x-ray. She received a chiropractic referral by her physician with improvement noted after the second chiropractic visit. Based upon the submitted records, it appears only six chiropractic treatments were certified between October 2004 and February 2005, a four-month span. The patient has requested authorization for continued chiropractic care. This patient has chronic lower back pain with documented degenerative changes. Six chiropractic treatments were provided between October 2004 and February 2005. A 40% improvement was stated after the second treatment. Considering the patients degenerative changes in her lumbar spine and her lack of response to physical therapy and NSAIDs, an additional six chiropractic treatments are medically appropriate and indicated to determine the patients treatment response. Based upon the information provided above, I have determined the requested services are medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned. The patient should receive six additional chiropractic sessions with re-evaluation at the completion of the six sessions.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for tramadol 50 mg and prednisone 20 mg. The records provided for review that this patients diagnoses include cervical radiculopathy, myofascial pain and migraines. Although tramadol and prednisone may be helpful in the short-term to reduce the pain from these conditions, these agents are not ideal for the management of these conditions. Neuropathic pain medications such as gabapentin, Cymbalta or pregabalin are likely to be more helpful in reducing the patients neuropathic pain. Furthermore, first-line migraine therapies such as triptans and tricyclic antidepressants are considered the standard of care for the management of migraines. Based on a review of the records provided, the patient has not failed treatment with or has a contraindication to these medications. As such, the requested tramadol 50 mg and prednisone 20 mg are not medically necessary for treatment of this patient.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 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: Urgent Care
Decision: Upheld

A 34-year-old male enrollee has requested emergency services for the treatment of his back condition. Findings:  The physician reviewer found that the patient experienced severe pain after the injury and sought medical treatment for diagnosis and treatment of the cause of the pain. Thus, the initial visit to the physician would meet the prudent laypersons definition of an emergency. However, the surgery itself would not meet the laypersons definition of an acute emergency. The patient was not losing any function and the surgery took place four days after the injury occurred. The acuity of the need for surgical intervention is in question. There is no documentation in the medical record to support the conclusion that the patient was at risk for paralysis. Therefore, the medical and surgical services received by the patient were not medically necessary to treat his condition.
Appeal type: Urgent Care
Decision: Overturned

The parent of a male enrollee requested urgent care services on an emergent or urgent basis. Findings:  The physician reviewer found that review of the submitted clinical documentation demonstrates that a prudent layperson would have sought immediate medical attention on the date in question.  The patients condition could have potentially led to serious dysfunction of his ankle and long-term disability. Further, it has been established that criteria for urgently needed services were met.  In this case, the patients presentation was significant for acute right ankle sprain. Based on the documentation submitted for review, a prudent layperson in a similar situation would have believed immediate medical attention was necessary to prevent serious deterioration of ones health. In sum, based on the patients clinical presentation he did meet prudent layperson criteria for urgently needed services.
Appeal type: Medical Necessity
Decision: Overturned

A 60-year-old male enrollee has requested Viagra for the treatment of his erectile dysfunction. Findings:  The physician reviewer found that the submitted clinical information indicates the patient has erectile dysfunction (ED) that has responded to treatment with oral Viagra. The patient has a documented history of hyperlipidemia, though his current cholesterol levels are unknown. Regardless of the source of the patients erectile dysfunction, Viagra is considered a first-line therapy. It has apparently been an effective treatment for the patients ED. There are no contraindications to the medication based upon the information provided, and the patient should continue to receive Viagra for appropriate management of his ED.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested a referral for acupuncture services for treatment of her medical condition.  Findings:  The physician reviewer found that there is sufficient support for the requested services in this patients case.  In regards to the chronic lower back complaints, acupuncture may be recommended as an option for chronic low back pain using a short course of treatment in conjunction with other interventions.  Acupuncture has been found to be more effective than no treatment for short-term pain relief in chronic low back pain.  Regarding the use of acupuncture for the knee osteoarthritis, recent clinical trials concluded that acupuncture treatment of knee pain produces significant improvement in physical capability and psychological functioning.  All told, the requested referral for acupuncture services is medically indicated for the treatment of this patient.Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in oriental 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: The patient has requested authorization and coverage for a Durolane injection in both knees. 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 relief from prior intra-articular injections of Durolane into both knees. Given the patients limited options and based on the current medical literature, the requested services are medically indicated. Therefore, a Durolane injection in both knees is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/ Case Summary:  The enrollees parent is requesting authorization and coverage for the medication, Dupixent. This enrollee has moderate-to-severe atopic dermatitis. He was partially controlled on methotrexate with persistent, chronic dermatitis and severe impairment of quality of life. The physician reports methotrexate has impaired his sleep, social activities, and normal school activity. The physician recommends switching to Dupilimab. This enrollee has failed standard topical and systemic therapy, according professional society guidelines for atopic dermatitis. Atopic dermatitis is known to cause considerable psychosocial dysfunction in both children and adults. Control of atopic dermatitis is important to prevent complications of disease, including lichenification, scarring, and cutaneous infection. When considering the severity of this enrollee's disease, lack of response to topical corticosteroids, oral methotrexate, expected lack of response to topical calcineurin inhibitors, need to prevent worsening severity, and to improve quality of life, Dupixent for this enrollee's atopic dermatitis is an appropriate choice.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 dermatology 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

A male enrollee requested for Harvoni for medical treatment of his hepatitis C.  Findings:  Two physician reviewers found that the submitted documentation fails to demonstrate the medical necessity of the requested medication.  This patient has minimal liver disease based upon the records.  At this time, the patient is asymptomatic without extrahepatic manifestations of hepatitis C.  There are no other liver diseases occurring, such as nonalcoholic steatohepatitis, and the patient is not immunosuppressed.  The current medial evidence supports serial monitoring in this clinical setting.  Therefore, Harvoni is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 53-year-old male with a long history of neck pain from anterior cervical degenerative joint disease, and chest pain in 2003 from pericarditis, requesting coverage for Bextra 20mg twice daily. The patient also has a history of diverticulitis and chronic gastritis for which he is on Prevacid. The patients provider states that Cox II inhibitors have not helped relieve the patients chest pain, and Bextra has been very effective in providing relief of his chest pain.I find that the requested dosage of Bextra is higher than the manufacturers recommended dosage. Since NSAIDs have adverse side effects that are dose related, the patient should not exceed the manufacturers recommended dosage. As such, the use of Bextra at the requested dosage is not medically indicated. Therefore, I have determined that the requested prescription is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

A 62-year-old male has requested coverage for a past MR neurography performed for evaluation and treatment of his shoulder weakness.  Findings:  Two physician reviewers found that the patient presented with complaint of right shoulder weakness following a lymph node biopsy procedure. The provider recommended a nerve graft procedure to address the patients symptoms of pain and atrophy in the brachial plexus region of the right shoulder. The patient underwent MR neurography in preparation for the recommended procedure.  MR neurography is capable of generating high resolution longitudinal and cross sectional images of major peripheral nerves, and has been studied to supplement diagnostic evaluations by electromyography (EMG) and nerve conduction studies in patients with suspected peripheral nerve tumors, traumatic injury, post-irradiation neuritis, chronic compression, and pain syndromes where an anatomic lesion is suspected. Although current evidence supports MR neurography as a promising technique, the outcome data which would determine the efficacy of this technology is limited to studies involving a small number of patients, making it premature to offer conclusions regarding its effectiveness for the general population. Additionally, large-scale, well-conducted, controlled studies with this approach are warranted to determine its efficacy in imaging neurofibromas and distinguishing benign from malignant lesions.MR neurography is not considered a first line technique and should only be used to supplement other diagnostic evaluations. In this patients case, there is no indication in the records provided that he had additional nerve conduction studies, EMGs, or conventional radiological examinations prior to the MR neurography being performed. Given that there is no documentation that other studies had been performed in the work-up of this patient, the diagnostic procedure at issue was not likely to have been more beneficial for evaluation and treatment of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 49-year-old man with long-standing lateral epicondylitis. He has attempted treatment with several modalities including physical therapy, prescription pain relievers, nonsteroidal anti-inflammatories, and steroid injections. The patient continues to experience pain and wishes to undergo extracorporeal shockwave therapy for treatment of lateral epicondylitis. The Health Plan has denied his request on the basis that extracorporeal shockwave therapy is not medically necessary for treatment of the patients medical condition.Extracorporeal shockwave therapy for treatment of lateral epicondylitis is not considered to be standard of care. A recent article in the Journal of Bone and Joint Surgery found that the procedure had little benefit and therefore, was not recommended. The current scientific literature does not demonstrate the efficacy of the requested therapy or the associated complications or risks. The requested therapy is not medically indicated for this patient since it is not likely to be beneficial. 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.