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

The parent of a four-year-old female enrollee has requested speech therapy for the treatment of the enrollees pervasive developmental disorder, not otherwise specified. Findings:  Three physician reviewers found that this patient presents with developmental delays with assessments indicating autism spectrum disorder symptomatology, a complex neurodevelopmental disorder. Speech and language therapy has been recommended. Medical records establish speech and language delays. As noted in the article by Myers and colleagues, the primary goals of treatment of autism spectrum disorder are to maximize the patients ultimate functional independence and quality of life by minimizing the core autism spectrum disorder features. The article identifies speech and language intervention as an appropriate treatment modality in this setting. This is also consistent with the practice guidelines of the American Academy of Child and Adolescent Psychiatry, which state that the treatment of autism spectrum disorder requires the care of multiple providers with various treatment modalities such as pharmacotherapy, speech-communication therapy and behavior modification. All told, speech therapy is clinically appropriate and indicated for this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a total hip arthroplasty using the anterior approach. Findings:  The physician reviewer found that the choice between anterior approach and posterior approach in primary total hip arthroplasty remains controversial. In the first study referenced below, patients treated with the anterior approach reported less pain, consumed fewer narcotics, and reported better hip function. There were no statistical differences in complication rates between the anterior and posterior approach patients. According to the second study referenced below, the surgical procedure time is longer with the anterior approach, but the incision is shorter, pain is less, patients require less opioid medication, and the length of stay is shorter. The anterior approach goes between muscles, hastening the subsequent rehabilitation and preventing muscle atrophy. There is sufficient support for the requested services in this clinical setting. Therefore, a total hip arthroplasty using the anterior approach 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: Upheld

A 45-year-old female enrollee requested authorization and coverage of acute rehabilitation services. The Health Plan  denied the request indicating that the requested services are not medically necessary for treatment of the enrollees multiple sclerosis. One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested services are not medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for genetic testing. Findings:  The three physician reviewers found that The prothrombin G20210A mutation has been associated with thrombosis and adverse pregnancy outcomes. One such adverse pregnancy outcome is recurrent early pregnancy loss. While meta-analyses and a retrospective cohort study have revealed an association between inherited thrombophilia's and first-trimester pregnancy loss, prospective cohort studies have found no association between inherited thrombophilias and fetal loss. Moreover, methylenetetrahydrofolate reductase (MTHFR) mutations have not been found to convey an increased risk for venous thromboembolism or pregnancy complications. As such, genetic testing was not indicated for further evaluation of this patients medical condition. Given these findings, the genetic tests were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Findings:  Three physician reviewers found genetic tests were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that genetic tests 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: Physician reviewer 1 is board certified in obstetrics and gynecology and are actively practicing. Physician reviewer 2 is board certified in obstetrics and gynecology with subspecialty certification in maternal and fetal medicine and are actively practicing. Physician reviewer 3 is board certified in obstetrics and gynecology 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: Experimental/Investigational
Decision: Overturned

A 42-year-old female enrollee has requested a wireless capsule endoscopy procedure for evaluation of her anemia. Findings:  Three physician reviewers found that a wireless capsule endoscopy is likely to be more beneficial for the patient than any available standard treatment. The patient has obscure, occult gastrointestinal bleeding. Recent literature suggests that wireless capsule endoscopy is superior to other studies for the detection of a small bowel source of bleeding.  The clinical decision in this case is to pursue a workup rather than empiric treatment with iron. Under the circumstances, wireless capsule endoscopy is the appropriate choice for evaluation of the patients condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for lidocaine patches, 5%. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the patients chronic back pain with severe sciatica. The submitted documentation does not support the medical necessity of the requested medication quantity. In a prospective randomized double blind trial, the Lidoderm patch was no better than placebo in treating low back pain. According to researchers, this lack of effect was studied by using functional magnetic resonance imaging. The results showed that there was not a significant benefit as compared to placebo. The requested medication has not been proven effective for chronic back pain and is not medically reasonable or necessary in this clinical setting. Therefore, lidocaine patches, 5% are not medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in anesthesiology with sub-specialty certification in pain management 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 authorization and coverage for Forfivo XL 450 mg. Bupropion is a dual-acting medication that enhances both noradrenergic and dopaminergic tone in the central nervous system. The medication was approved by the U.S. Food and Drug Administration (FDA) for treatment of depression in 1989 and has established itself as a reliable and well-tolerated anti-depressant. A twice per day sustained acting preparation was released in 1996, followed by the once-daily extended-release (XL) formulation in 2003, and then the Forfivo preparation in 2012. Forfivo provides a unique benefit to patients as it allows for the maximum daily dosage of 450 mg to be delivered in a single tablet, rather than a multi-dose combination, which optimizes treatment adherence without increasing the risk for side effects. Thus, Forfivo is a reasonable treatment intervention for patients with major depressive disorder. In this case, the provider noted that the patient requires this long acting medication. Further, the documentation supports that the patient failed standard alternatives and has been doing well on this formulation of the medication. The intervention is consistent with good medical practice and reasonably expected to improve his depression and prevent an exacerbation of illness. For these reasons, the requested Forfivo XL 450 mg is medically necessary for treatment of this patients attention deficit hyperactivity disorder (ADHD). 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 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

The parent of a 10-year-old male enrollee has requested orthoptic training services for treatment of the enrollees convergence insufficiency and ocular motor dysfunction. Findings:  Two physician reviewers found that the orthoptic training services were not likely to be more effective for this patient than other available options. A review of the patients chart and applicable medical diagnoses discussed above do not support a vision therapy program. Evidence based research does not support or demonstrate that convergence insufficiency as a non-isolated diagnosis in the presence of a combination of other issues such as ADHD and learning disabilities, which can be remedied by vision therapy programs.  Moreover, according to the American Academy of Pediatrics vision problems can interfere with learning; however, vision problems are not the cause of primary dyslexia or learning problems. There is a lack of evidence for a vision therapy program having had any direct impact on the broader issue of  ocular motor dysfunction related to this patients learning issues. Therefore the services at issue were not likely to be more beneficial treatment than standard medical therapy in this clinical setting.
Appeal type: Urgent Care
Decision: Upheld

An enrollee has requested reimbursement for dental services provided. Findings:  The physician reviewer found that California law defines emergency services and care as medical screening, examination, and evaluation by a physician and surgeon, or, to the extent permitted by applicable law, by other appropriate licensed persons under the supervision of a physician and surgeon, to determine if an emergency medical condition or active labor exists and, if it does, the care, treatment, and surgery, if within the scope of that person's license, necessary to relieve or eliminate the emergency medical condition, within the capability of the facility. A screening examination in an emergency department, and any medical services received from on-call specialists in the emergency department, are, by definition, an emergency medical service. The dental services provided were not necessary for treatment of an emergency medical condition. There was no emergent medical condition noted in the records submitted for review. The progress notes do not describe a complaint of pain. Although the patient states that he presented with severe pain, this is not documented in the records submitted for review. Given that the records provide no notation of pain or infection associated with the patients tooth there is no indication that the patient received emergency dental services. In sum, the services at issue were not necessary for treatment of an emergency dental condition. Thus, the patient did not receive emergency dental services on the dates of service at issue. Final Result: The reviewer determined that the patient did not receive emergency dental services on the dates of service at issue. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in dentistry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 59-year-old male who has been diagnosed with hepatitis C. He was initially treated with interferon and ribavirin in 1998 with complete viral remission. He was treated again in 2001 due to a relapse. In 2003, the patient began a course of Peg-Intron with ribavirin, which he has been on for one year. An additional six months of therapy has been requested.It is not the standard of care to extend a course of Peg-Intron with ribavirin beyond 12 months. The Food and Drug Administration indication in terms of length of therapy is quite clear. There is no prospective, peer-reviewed study showing benefit in treating patients for 18 months rather than 12 months. Thus, an extended course of Peg-Intron with ribavirin therapy is not likely to benefit the patient and is not medically indicated. 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.
Appeal type: Experimental/Investigational
Decision: Upheld

A 59-year-old male enrollee has requested magnetic resonance (MR) spectroscopy for evaluation of his prostate cancer. Findings:  Three physician reviewers found that in this case, the requested services are not likely to be more effective than other modalities for evaluating this patient.  There is a lack of support in the current medical literature demonstrating that superior efficacy of MR spectroscopy in this clinical setting.  Currently, peer-reviewed studies are limited and have not demonstrated benefit over current protocols of active surveillance which rely on PSA testing, digital rectal examinations, and repeat biopsies.  All told, the requested MR spectroscopy is not likely to be of greater benefit than other available options in this setting.
Appeal type: Medical Necessity
Decision: Upheld

Findings:  The physician reviewer found that an enrollee has requested authorization and coverage for Enbrel SureClick 50 mg/mL, two times weekly. There is a lack of support for the requested medication dosage in this patients case. As noted by researchers, in the case of biologic agent treatment failure due to either adverse events or inefficacy, a large volume of observational data are now available supporting the conditional recommendation of switching either to an alternative biologic agent within a drug class or to a drug with a different mode of action. There is a lack of large phase III randomized controlled studies which demonstrate efficacy and safety or recommend accelerated dosing of a tumor necrosis factor inhibitor for the treatment of psoriatic arthritis. The medical evidence supports switching agents in this setting. Therefore, Enbrel SureClick 50 mg/mL, two times weekly is not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medication dosage 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 rheumatology 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: The enrollee has requested authorization and coverage for a consultation with a surgeon. The Health Plan has denied this request indicating that the requested service is not medically necessary for treatment of the enrollees chronic obstructive pulmonary disease, morbid obesity, and rheumatoid arthritis. A review of the records indicates that the enrollee has been diagnosed with chronic obstructive pulmonary disease, morbid obesity, and rheumatoid arthritis. The enrollees provider noted that the enrollee had been using a wheelchair. Knee pain was also noted. The enrollee was noted to have tried dieting but was unsuccessful with weight loss. The enrollee bariatric was 5 feet 7 inches tall, and weighed 323.3 pounds. The enrollees body mass index (BMI) was 50.62. The enrollees provider has recommended a consultation with a bariatric surgeon for the enrollee.Bariatric surgery is a reasonable consideration for adults with a BMI =40 kg/m2, or a BMI of 35 to 39.9 kg/m2 with at least one serious comorbidity, who have not met weight loss goals with diet, exercise, and drug therapy. In this case, the enrollee is morbidly obese, with a BMI of 50.62 but there has been no formal trial of weight loss through diet and/or drug therapy. The only medical documentation regarding prior diet trial generally describes that prior weight loss attempts through diet have not been successful. Because there has not yet been an adequate trial of medical weight loss (diet, pharmacologic interventions), the requested consultation with a bariatric surgeon is not medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the requested service 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 family practice 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 radiofrequency ablation of a cancerous lesion of the left lobe of the liver for treatment of his medical condition.  Findings:  Three physician reviewers found that treatment for metastatic neuroendocrine tumors is considered palliative.  Treatments have been designed to decrease tumor burden and subsequent symptoms.  Progression-free survival and overall survival has been improved with treatment, especially in those with liver only disease.  Surgery is a first-line therapy.  However, management of the liver metastases can vary depending on location, size, liver function, and extrahepatic tumor burden.  Treatment decisions are often made in the multidisciplinary forums to review films and discuss options.  With progressive disease, the decision was made to proceed with ablation.  This is reasonable as it preserves as much liver function as possible while effectively treating the growing lesions.  There is sufficient support for the requested services in this clinical setting.  All told, the requested services are likely to be of greater benefit than other treatment options.  Final Result: Three 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 reviewers are board certified in surgery 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

A 49-year-old male enrollee requested authorization and coverage of proton beam radiation therapy. The Health Plan  denied the request indicating that the requested therapy is not medically necessary for treatment of the enrollees squamous cell carcinoma.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested therapy is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for sacroiliac (SI) joint injection. Findings: In this case, the providers notes state that the patient has low back pain radiating into the right lower extremity consistent with the nerve distribution of L4, L5, and S1. A magnetic resonance imaging (MRI) confirms narrowing of the neural foramina at L4-5, and CT demonstrated disc protrusions at L 4-5 and L5-S1, which are consistent with the patients symptoms. The providers note state the straight leg test was positive at 45 degrees, which is suggestive of a lumbar radicular pain pattern and not an SI joint pain pattern. According to the American Society of Interventional Pain Physicians (ASIPP) guidelines, documentation should include three separate provocative tests on the SI joint itself to establish a higher diagnostic probability that the SI joint is the pain generator. The notes state the Patricks test was positive. However, the records do not report that the provider performed a Gaenslens test or other SI joint provocation tests. The providers diagnostic impression is lumbar radiculopathy and not an SI-joint related cause for back pain that does not travel down the leg. A review by Thawrani and colleagues outlines that an SI joint injection is indicated for suspected SI joint related pain and not lumbar radicular pain. This patient has lumbar radicular pain. Based on the medical records for review and the current evidence based medical literature, the requested SI joint injection to treat lumbar radicular pain is not medically necessary.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 anesthesiology with subspecialty certification in pain management 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.