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

Nature of Statutory Criteria/Case Summary:  An enrollee has requested an orthopedist specialist opinion for treatment of his right knee condition.   The physician reviewer found that the submitted documentation supports the medical necessity of the requested services.  This patient has multiple comorbidities, including diabetes mellitus with peripheral neuropathy, hypertension, and tobacco use disorder.  It is appropriate for the patient to be evaluated by an orthopedic surgeon for an informed discussion of operative and nonoperative management of his documented knee osteoarthritis.  The orthopedic surgeon may be able to offer minimally invasive treatments that could be tolerated by the patient, in addition to recommendations regarding kinesiotherapy, exercise therapies, weight reduction, smoking cessation and a more careful management of diabetes mellitus.  All told, the requested orthopedist specialist opinion 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 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: Experimental/Investigational
Decision: Upheld

A 75-year-old female enrollee has requested sacroplasty for treatment of her sacral fracture. Findings:  Two physician reviewers found that in early studies, promising results were reported with vertebroplasty and kyphoplasty. Whitlow and colleagues found that these findings were followed with attempts to apply the technique to the sacrum with comparable results. However, Bayley and colleagues caution that there is a need for more robust evidence to validate these reports, In addition, Jayaraman and colleagues concluded that there remains a need for further evaluation of the procedure. Similarly, Richards and colleagues found that laboratory studies have not demonstrated restoration of strength of the sacrum. Moreover, Kallmes and colleagues found that randomized studies of vertebroplasty outcomes have shown similar improvement in treated and control groups. For these reasons, the safety and efficacy of the requested sacroplasty has not been established in the clinical literature and is not therefore expected to provide this patient with better results than proven therapies.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a 13-year-old male enrollee has requested for the growth hormone therapy (Nutropin AQ) for treatment of the enrollees short stature.       Findings:  The physician reviewer found that given that the patient is not short, and that he does not appear destined to become a short adult, there appears to be no medical indication for GH therapy in this instance. However, the crossing of percentiles in linear growth does indicate a need for further observation.
Appeal type: Medical Necessity
Decision: Upheld

An 18-year-old female enrollee has requested continued eating disorder residential treatment for the treatment of her anorexia nervosa. Findings:  The physician reviewer found that the American Psychiatric Association (APA) guidelines for eating disorders specifically state, The decision about whether a patient should be hospitalized on a psychiatric versus a general medical or adolescent unit should be made based on the patients general medical and psychiatric status Further, the guidelines clearly indicate that every attempt should be made to prevent physiological instability, as it may be associated with sudden and catastrophic cardiac consequences. The criteria provided by the American Academy of Pediatrics (AAP) are quite similar. This is a very seriously ill individual with a body weight at a dangerously low level. She was not gaining weight and her condition was becoming a more serious safety risk. This patient required admission to an acute inpatient treatment program. She requires on-going inpatient medical care until she is physiologically stabilized. After stabilization, treatment in a residential facility would likely be appropriate.
Appeal type: Medical Necessity
Decision: Upheld

A 20-year-old male enrollee has requested continued residential rehabilitation services for treatment of his polysubstance abuse.  Findings:  The physician reviewer found that per the American Society of Addiction Medicine (ASAM) criteria, the requested continued residential rehabilitation services are not supported as medically necessary for treatment of this patients medical condition. The records indicate the patient has a stable home environment which is supportive and he is not demonstrating ongoing suicidal ideation or intent. He is not a danger to others and is not demonstrating aggressive behavior. He does not have any noted comorbid medical conditions or psychiatric conditions which require 24-hour treatment. In addition, the patient shows a readiness and willingness to change as manifested by his involvement and progress within the 12 step program. Further, the patient is no longer in the acute detoxification phase. All told, the patient does not meet the criteria for acute residential treatment and can safely be treated at a lower level of care. Therefore, the requested services are not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 37-year-old female enrollee requested authorization and coverage of an MRI of the lumbar spine and an MRI of the pelvis. The Health Plan denied the request indicating that the requested MRIs are not medically necessary for the evaluation of the enrollees back pain and uterine fibroid.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer partially overturned the Health Plans denial on the basis that the requested MRI of the lumbar spine is medically necessary, however, the requested MRI of the pelvis is not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 17-year-old female enrollee has requested for psychiatric residential treatment for treatment of the enrollees mental health conditions. Findings:  The physician reviewer found that the medical records also reflect ongoing medication management and family therapy. The ability to respond to intense residential treatment is evident. Discharge planning is included in the current plan of care, but this requires continued care at the present level of care, as well as intense planning and coordination (given this patients psychiatric history and major co-morbidities).
Appeal type: Medical Necessity
Decision: Upheld

A 28-year-old male enrollee has requested transcranial magnetic stimulation (TMS) treatments for his depression.  Findings:  The physician reviewer found that in the absence of documentation in the patients clinical records, there is no support for the presence of a distinct, acute major depressive episode in December 2012. Additionally, the requesting provider has recommended a booster or maintenance TMS. Although the evidence may be promising, the utility of TMS in long-term or maintenance treatment for major depressive disorder has not yet been established by the scientific community. For patients who respond to repetitive TMS, one should attempt to maintain the remission with prophylactic oral medications (George, et al). Given the records provided for review and within the context of the most current practice guidelines and relevant peer-reviewed literature, any application of TMS as maintenance, preventative or long-term therapy for major depressive disorder is not supported as medically necessary. Therefore, the TMS treatments provided during the said timeframe were not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Xifaxan. A study notes that rifaximin treatment appears effective and safe for the treatment of small intestine bacterial overgrowth (SIBO). Another study found that rifaximin effectively normalized the glucose hydrogen breath test (GHBT) and reduced the symptoms of irritable bowel syndrome (IBS) by possibly counteracting SIBO. An additional study notes that rifaximin plus neomycin is superior to neomycin alone in improving multiple constipation-predominant IBS symptoms. In this case, the patient has diagnoses of IBS with constipation and SIBO. While antibiotics such as fluoroquinolones may address bacterial overgrowth, they would not be expected to improve irritable bowel syndrome. Given the current medical literature, the requested medication is medically indicated in this clinical setting. Therefore, Xifaxan 550 mg tablets 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 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: Experimental/Investigational
Decision: Overturned

A 65-year-old male enrollee has requested Botox injections for the treatment of his Parkinsons disease. Findings:  Two physician reviewers found that Botox is indicated for abnormal muscle tone related to neurodegenerative disease. This patients symptoms fit this classification.  In addition, Singer, et al. and Quirk, et al. support the use of Botox in scenarios such as this, making its use in this particular case medically reasonable, appropriate, and likely to be more efficacious for the patients symptoms than other available treatments.
Appeal type: Experimental/Investigational
Decision: Upheld

A 44-year-old female enrollee has requested an osteochondral allograft transplant of the right ankle for the treatment of her right ankle condition. Findings:  Two physician reviewers found that the use of allograft transplant for such an extensive lesion is not supported by Level I-III evidence. While in such a difficult case ongoing problems after arthrodesis are likely, the proposed allograft transplant is not likely to be result in a superior outcome for this patient and will likely fail with subsequent need for further procedures.
Appeal type: Experimental/Investigational
Decision: Upheld

An enrollee has requested authorization and coverage for cardiac computed tomography (CT) without contrast with quantitative evaluation of coronary calcium. Based on the documentation provided for review, this patient has increased coronary risk but no evidence of coronary artery disease. In this circumstance, guidelines for the management of cardiac risk and dyslipidemia currently do not recommend routine performance of specialized tests in the context of assessing coronary risk including coronary CT scanning and calcium scoring. Treatment changes or addition based on the results of screening with coronary CT scanning have not been shown to improve cardiac outcome incremental to that achievable with treatment based on a combination of standard risk factor profiling and basic lipid analysis. Thus, the requested cardiac CT without contrast with quantitative evaluation of coronary calcium is not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested services are not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewers 1, 2, and 3 are board certified in internal medicine with subspecialty certification in cardiovascular disease and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 23-month-old female enrollee has requested authorization for speech therapy for treatment of the enrollees moderate expressive language impairment. Findings:  The physician reviewer found that speech and language development is considered by experts to be a useful indicator of a childs overall development and cognitive ability and is related to school success. Speech and language delay must be taken seriously in young children, because the long-term consequences may be substantial.Studies have shown that speech and language therapy can result in significant improvement in this clinical setting.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for (1) platelet-rich plasma (PRP) injections two times in a six-month period (every three months) for each knee, or (2) a PRP injection in each knee. Researchers note, Currently, the literature remains divided regarding the overall effectiveness of leukocyte-rich PRP for the treatment of orthopedic diseases, namely osteoarthritis. There is still no general consensus on this subject since leukocyte-rich PRP has shown both positive and negative results according to different animal studies. There are no clinical studies specifically evaluating the use of leukocyte-rich PRP alone for knee osteoarthritis. The use of PRP is not currently included in specific recommendation per the American Academy of Orthopaedic Surgeons for the treatment of knee osteoarthritis. Therefore, (1) PRP injections two times in a six-month period (every three months) for each knee, or (2) a PRP injection in each knee are not likely to be more beneficial for treatment of the patients condition than any available standard therapy.Findings:  Two of the three physician reviewers found the requested (1) PRP injections two times in a six-month period (every three months) for each knee, or (2) a PRP injection in each knee are 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 reviewers 1, 2, and 3 are board certified in orthopedic surgery and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested testosterone gel for treatment of the enrollees hormone replacement therapy.  Findings: The physician reviewer found that Testosterone replacement therapy can improve the signs and symptoms of low testosterone in men (Miner, et al). However, the data for testosterone replacement therapy remains inconclusive for the female population. For this reason, testosterone replacement therapy has not been approved by the U.S. Food and Drug Administration (FDA) for female patients (Nappi). Moreover, there is a lack of data supporting the off-label use of testosterone gel for patients in this clinical setting. All told, the requested testosterone gel is not medically necessary for treatment of this patients medical condition.Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in endocrinology, diabetes, and metabolism 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

A 69-year-old female enrollee has requested Synvisc injections (right knee) for the treatment of her osteoarthritis. Findings:  Two physician reviewers found that repeat administration of hyaluronic acid (Synvisc) is a safe, effective and valid treatment alternative. In this patients case, her only alternative to viscosupplementation would be total joint replacement. Review of her history suggests that she is still highly functional and that she does not feel her quality of life is so compromised that total knee replacement is her only option. She ambulates independently and has up to 130 degrees of knee flexion, with apparently full extension. Synvisc injections are a conservative alternative to knee replacement and are medically indicated and appropriate for this patient.
Appeal type: Medical Necessity
Decision: Overturned

A representative of a 63-year-old female enrollee requested authorization and coverage of skilled nursing facility services. The Health Plan denied the request indicating that the requested services are not medically necessary for treatment of the enrollee status post left humerus and left knee fracture.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plans denial on the basis that the requested services are medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patients parent has requested reimbursement for Residential treatment center (RTC) services. Medical literature shows a criteria for adolescents is useful to determine the appropriate level of care of mental health services. Dimension 1 requires documentation of acute withdrawal. The patient did not demonstrate symptoms of acute withdrawal as evidenced on physical examination. Dimension 2 evaluates a patients biomedical conditions, which were not present in this case. Dimension 3 requires documentation of emotional, behavioral or cognitive conditions. The patient meets this criterion as he had sufficient mental status to permit participation and demonstrated an inability to control his impulses. The patient also demonstrated significant functional deficits including refusal to attend school and the presence of family conflict. For Dimension 4, readiness to change, he demonstrated opposition to addressing substance use problems and attributed his substance use problems to other people. For adolescents, ASAM 3.5 criteria require that the patient meet two out of six-dimensional criteria. After reviewing the documentation, the patient met the criteria in the emotional, behavioral, cognitive conditions and readiness to change dimensions. Therefore, the RTC services provided were medically necessary for the treatment of this patient.Final Result: The reviewer determined that the services at issue were 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 psychiatry with subspecialty certification in child and adolescent psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 55-year-old male enrollee has requested an artificial intervertebral disc replacement procedure for the treatment of his cervical disc herniation and pain. Findings:  Three physician reviewers found that there is insufficient data to establish the long-term safety and efficacy of disc replacement. In addition, the data does not establish disc replacement as more beneficial than other available procedures. Furthermore, there have been significant re-operations associated with disc replacement.
Appeal type: Experimental/Investigational
Decision: Overturned

A 62-year-old male enrollee has requested a real-time cardiac monitoring device for evaluation of his recurrent atrial fibrillation. Findings:  Two physician reviewers found that this is a patient with recurrent symptomatic atrial dysrhythmias. He has recurrent palpitations, possibly due to atrial dysrhythmias and apparently and electrocardiography (EKG) suspicious for Brugada syndrome. The presence of either ventricular tachycardia or atrial fibrillation episodes on ambulatory monitoring would markedly change the diagnostic and therapeutic plan for this patient. With the real-time telemetry monitoring, when the rhythm occurs without external induction, therapy can be directed towards the rhythm. The absence of the rhythm on a 24-hour monitor would not exclude the possibility of these rhythms occurring with symptoms given the shorter time duration of the Holter monitor.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The parent of a 14-year-old female enrollee has requested reimbursement for allergy testing services performed by Foundation Labs, LLC. Medical literature notes that the general approach to diagnosis of food allergy include modalities such as medical history, physical examination, elimination diets, skin prick tests, allergenspecific serum immunoglobulin (Ig) E measurements, and oral food challenges. While the measurement of IgE levels to specific foods in question may be included as part of a food allergy evaluation, the current medical literature does not support the use of an extensive array of blood tests that examine aeroallergen component IgE and food IgG4 testing. The blood testing at issue is not demonstrated as being of any benefit in the evaluation of food allergies. Therefore, allergy testing services performed on by Foundation Labs, LLC, were 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 allergy testing services performed by Foundation Labs, LLC, at issue were not likely to have been beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the services at issue were 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 and in allergy and immunology and is actively practicing. Physician reviewer 2 is board certified in allergy and immunology and is actively practicing. Physician reviewer 3 is board certified in allergy and immunology and in pediatrics 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.