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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for bilateral L4-5 decompression with interlaminar device for treatment of the enrollees low back pain. Findings:  Two physician reviewers found that the current peer-reviewed literature and long-term studies support the use of Coflex interlaminar stabilization with decompression as a safe and efficacious alternative to decompression and/or lumbar fusion for the treatment of lumbar spinal stenosis and low-grade spondylolisthesis.  This patient presents with persistent low back pain radiating into the left lower extremity with numbness.  Functional difficulty was reported in ambulation.  Her signs and symptoms were consistent with imaging evidence of moderate to severe lumbar stenosis with grade 1 spondylolisthesis at L4-5.  Detailed evidence of comprehensive nonoperative treatment protocol trial and failure has been submitted. Final Result: Two reviewers determined that the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: All three physician reviewers 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

A 30-year-old female enrollee requested authorization and coverage of a continuous positive airway pressure (CPAP) device. The Health Plan denied the request indicating that the requested equipment is not medically necessary for treatment of the enrollees obstructive sleep apnea.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested equipment is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

A 33-year-old female enrollee has requested for chiropractic services for treatment of her neck and back pain. Findings:  The physician reviewer found that there is no indication as to what these activities are, nor any indication as to the patients frequency or progression of the home therapy. In addition, there is no evidence of objective findings (with relation to restoration of lost function and/or changes in range of motion, provocative assessments and/or palliative care) from which to assess whether additional chiropractic treatment is likely to be of benefit. Finally, throughout the patients treatment course, there was little if any change in her subjective complaints and/or relief of symptoms.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Donnatal for treatment of her inflammatory bowel disease (IBD).  Findings:  The physician reviewer found that Donnatal is used to treat abdominal pain, bloating and cramps in patients with IBD. It is composed of atropine sulfate, hyoscyamine sulfate, phenobarbital, and scopolamine hydrobromide. The records indicate that this patient has tried and failed numerous agents and has a contraindication to the use of Lomotil. Further, the patient is currently maintained on four other pain medications. Donnatal is a combination product, which will prevent the patient from having to take four additional pain medications to control her condition. The combination product Donnatal is appropriate, has provided this patient with functional benefit, and is therefore medically necessary. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. 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: Upheld

A 49-year-old male enrollee requested authorization and coverage of the medication Vioxx, 50mg. The Health Plan  denied the request indicating that the requested prescription is not medically necessary for the treatment of the enrollees degenerative joint disease and post-traumatic arthritis.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested prescription is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

A 56-year-old male enrollee has requested acupuncture twice a month for treatment of his medical condition.  Findings:  The physician reviewer found that review of the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested therapy. In the absence of clinical documentation demonstrating that a flare up, functional regression, or functional limitations exist, the request for additional acupuncture care is not supported as medically necessary. In addition, the treatment plan does not include goals, the total number of acupuncture sessions to date, and quantifiable response to those treatments sessions in order to support the medical necessity of additional acupuncture treatment. Based on the reasons provided, acupuncture twice a month is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 59-year-old male with reported large right hemispheric arteriovenous malformation. He is status post treatment with gamma knife. The patient apparently experiences focal motor seizures. He has attempted treatment with Dilantin, which was unsuccessful due to adverse effects. The submitted records indicate the patient has been doing well on Trileptal. The Health Plan has denied authorization for Trileptal on the basis that it is not medically necessary since other antiepileptic drugs are available.The patient has tried and failed one antiepileptic drug for his focal seizures. Based upon the evidence provided, no antiepileptic drugs other than Trileptal have been tried by the patient. Other medications such as carbamazepine and Depakote are available and are likely to be effective. Thus, there is no medical indication for Trileptal at this time. However, if a trial of one of these medications results in failure or is intolerable, treatment with Trileptal would be appropriate. Therefore, I have determined that the requested medication is not medically necessary for treatment of the patients medical condition at this time. The Health Plans denial should be upheld at this time. The patient should undergo a trial of another antiepileptic medication such as carbamazepine or Depakote. If there is documented evidence that the trial is unsuccessful, then Trileptal should be authorized.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:    An enrollee has requested an acute inpatient stay for treatment of her medical condition. The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  This patient was admitted with mental decline and found to have HIV/AIDS related rapidly progressive dementia and probable lymphoma.  Initially, the enrollee received a chest tube due to an iatrogenic pneumothorax.   Subsequently, the enrollee was tolerating an oral diet, oral medications and had remained stable for 24 hours after removal of the chest tube.  The patient was stable and no further inpatient medical treatment was planned after that point.  She could have been safely discharged to a lower level of care.  All told, acute inpatient stay was not medically indicated 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 internal 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: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested back surgery for treatment of the enrollees back pain.  Findings: The physician reviewer found There is a lack of large volume, long-term peer-reviewed outcome studies to support the requested back surgery in this clinical setting. There is some medical peer-reviewed evidence to support the use of percutaneous balloon kyphoplasty for acute vertebral body fractures, less than three months from onset of pain to procedure. In this case, the patient had a traumatic T12 compression fracture that was 10 months old. She presented with moderate to severe persistent back pain. Moreover, other than the prescribed medications which the patient did not wish to take, there was a lack of evidence indicating that conservative treatment was performed. All told, the requested back surgery is not medically necessary for treatment of this patient.Final Result: The reviewer determined the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in 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: Overturned

A 45-year-old female enrollee has requested pulsed radiofrequency denervation of the left suprascapular nerve for treatment of her chronic pain, left shoulder, and adhesive capsulitis, left shoulder.  Findings:  Two physician reviewers found that the patient failed to receive benefit with minimally invasive surgery.  A more invasive surgery is not appropriate for treatment of chronic pain unless there is an involved mechanical disruption. The next logical step after failed conservative therapy would be pulsed radiofrequency denervation of the left suprascapular nerve for long-term improvement of the patients shoulder pain. More recently published medical literature have shown support for pulsed radiofrequency denervation in improving health outcomes associated with chronic pain Luleci and colleagues established a prospective study on the application of pulsed radiofrequency denervation to the suprascapular nerve for 480 seconds. The aim of the study was to evaluate patient satisfaction, efficacy and safety of the pulsed radiofrequency technique applied to the suprascapular nerve for treatment of refractory shoulder pain. Following the study, they concluded that pulsed radiofrequency technique application to the suprascapular nerve for 480 seconds showed remarkable improvement for individuals with chronic shoulder pain.Chua and colleagues published a prospective study to evaluate the efficacy of pulsed radiofrequency denervation treatment of chronic pain. They obtained their data from randomized clinical trials and well-designed observational studies. From the available evidence, they concluded that pulsed radiofrequency denervation of the suprascapular nerve was found to be as efficacious as intra-articular corticosteroid injections in patients with chronic shoulder pain.Liliang and colleagues performed a study in the clinical setting to evaluate pulsed mode radiofrequency lesioning of the suprascapular nerve for treating chronic shoulder pain. The cohorts of the study performed 13 procedures using pulsed radiofrequency lesioning of the suprascapular nerve under fluoroscopic guidance in 11 patients with chronic shoulder pain for at least three months. The authors found that pulsed radiofrequency lesioning to the suprascapular nerve is a potential treatment options for patients suffering chronic shoulder pain, as it provided long-term pain relief and decreased pain medication requirements in the participants of the study. Therefore, pulsed radiofrequency denervation of the left suprascapular nerve was likely to have been of greater benefit than any available standard therapy in this patients case.
Appeal type: Medical Necessity
Decision: Overturned

A 54-year-old female enrollee has requested authorization and coverage for Revlimid for treatment of her myeloproliferative disorder. Findings:  The physician reviewer found that the patient appears to have a hematologic disorder that has clinical overlap with myelodysplastic syndromes and myeloproliferative diseases.  The disease may have initially started as primary myelofibrosis.  The major risk for these patients is disease transformation into myelofibrosis and/or acute myeloid leukemia.  There is strong medical evidence supporting the use of Revlimid in myelofibrosis.  In two phase II trials, the requested medication resulted in improvements in anemia and thrombocytopenia.  The current medical evidence supports the requested medication in this patients case.  All told, Revlimid is medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:   An enrollee has requested a positron emission tomography (PET) scan and aquatic therapy for evaluation and treatment of her condition.   The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  This patient was admitted for surgical removal of back hardware and she reportedly tolerated the procedure without complications.  Subsequently, the patient was admitted for an acute flare of back pain.  Diagnostic studies at the time included x-rays of the spine that did not demonstrate any acute disease or concern for metastatic disease.  An abdominal ultrasound was unremarkable.  Later still, the records noted abdominal pain and chronic back pain, and physical therapy was declined by the patient for low back pain.  The records note that she has been started on omeprazole.  Lastly, the patients oncologist documented that the patient was stable.  In this case, the documentation does not support that the patient requires aquatic therapy instead of traditional physical therapy.  Therefore, the requested aquatic therapy is not medically necessary.  The diagnosis of gastric cancer is typically made with endoscopy.  A PET scan is not routinely used for the diagnosis or staging of gastric cancer.  In this case, the documentation submitted does not show that the patient has an active diagnosis of cancer or a concern for a recurrence of breast cancer.  Therefore, the requested PET scan is not medically indicated for the evaluation of this patient.  Final Result: The reviewer determined that the requested services are not medically necessary for evaluation and treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: The reviewer is board certified in internal 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: Experimental/Investigational
Decision: Upheld

A female enrollee requested the LINX Anti-Reflux procedure for medical treatment of her gastroesophageal reflux disease.  Findings:  Two physician reviewers found that The LINX Anti-Reflux procedure has been approved for lower esophageal sphincter augmentation.  Eligible candidates for the procedure include those with inadequate symptom control with acid suppression therapy, including those patients with mild to moderate gastroesophageal reflux disease and a hiatal hernia less than 3 cm.  Anti-reflux surgery is designed to provide benefit for many years, and this has not been demonstrated.  Moreover, there is a lack of controlled data comparing this technology to continued proton pump inhibitor therapy or fundoplication.  All told, the requested services are not likely to be of greater benefit than other treatment alternatives.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested intradiscal electrothermal annuloplasty (IDET) for treatment of her medical condition. Findings: The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  Despite the large number of procedures performed, a critical appraisal of the evidence of efficacy of IDET demonstrates that the evidence for efficacy of IDET remains weak and has not passed the standard of scientific proof.  The current medical evidence does not support the requested services in this patients case.  All told, the requested IDET is not medically indicated for the treatment of this patient.  Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: The reviewer is board certified in neurological 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the digital breast tomosynthesis for evaluation of the enrollees breast cancer examination. Findings:  Three physician reviewers found that the digital breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.  In this case, the patient has breasts that have been described as heterogeneously dense. While one could make the argument that her mammogram has not changed since the last study, it is specifically those patients who have dense breasts that can benefit most from tomosynthesis. In addition, the ability to separate out the overlapping structures enables the possibility of demonstrating or excluding an otherwise occult tumor. Final Result: The reviewers determined that the services at issue were 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 reviewers 1, 2, and 3 are board certified in diagnostic radiology and are 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 32-year-old male with chronic knee pain. He has undergone multiple surgical procedures without sustained benefit. The patient has requested authorization and coverage for a cryosurgery procedure, which has been denied by the Health Plan.The efficacy of cryosurgery for treatment of chronic knee pain has not been established. There are no long-term, prospective studies to warrant its use at this time. The long-term benefits of the procedure, if any, are unknown. Furthermore, the risks of the procedure remain unclear. Given the lack of evidence demonstrating that cryosurgery is likely to be beneficial for treatment of this patients knee pain, it is not medically warranted and cannot be recommended at this time. Therefore, I have determined the requested procedure is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested advanced lipoprotein testing for evaluation of his medical condition.  Findings:  Three physician reviewers found that the submitted records fail to demonstrate the superior effectiveness of the services at issue.  In this circumstance, secondary prevention guidelines for the management of cardiac risk and dyslipidemia have been established, are periodically updated by expert committees, and are endorsed by several national organizations.   These guidelines currently do not recommend routine performance of specialized tests in the context of assessing coronary risk including lipoprotein-associated phospholipase A2 (Lp-PLA2), sub-classifications of low-density lipoprotein (LDL), high-density lipoprotein (HDL) subclasses, lipoprotein(a), C-reactive protein, high sensitivity C-reactive protein, fibrinogen, genetic testing and homocysteine.  Treatment change or addition based on the results of screening with these specialized tests has not been shown to improve cardiac outcome incremental to that achievable by treatment based on standard risk factor profiling and basic lipid analysis.  Randomized trials testing treatment with therapy available to reduce homocysteine levels have not shown significant outcomes benefits.   Additionally, even though results of some of these specialized tests may be abnormal and considered independent risk markers for coronary disease, there is a lack of controlled trials that demonstrate outcome benefits by treating routinely obtained abnormal results.  Therefore, advanced lipoprotein testing was not likely to have been of greater benefit than other methods of evaluating this patient. Final Result: Three reviewers determined that the services at issue were 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: All three physician reviewers are board certified in internal medicine with sub-specialty 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 two-year-old female has requested occupational therapy for treatment of her autism. Findings:  The physician reviewer found that there is a significant body of medical literature that supports occupational therapy for autistic children. Myers, et al. recommends occupational therapy, however, it was also noted there is a paucity of literature concerning this modality in the treatment of autism. However, subsequent to the report by Myers, Case-Smith and Arbesman compiled a meta-analysis of the literature, documenting the value of occupational therapy in the autistic childhood population. Pfeiffer and colleagues found that occupational therapy is an efficacious therapy for reducing many of the unwanted mannerisms associated with autism. May-Benson and Koomar performed a meta-analysis of 27 journal articles utilizing sensory integration occupational therapy techniques for autistic children and concluded that the therapy was effective. All told, there is ample literature support for the use of occupational therapy in the treatment of children with autism.