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

A 53-year-old female enrollee has requested four consecutive weeks of pain injections in the neck (two facet joint injections and two epidural injections) for treatment of her cervical spondylosis.  Findings:  The physician reviewer found that four consecutive weeks of pain injections in the neck (two facet joint injections and two epidural injections) is not medically necessary for management of this patients medical condition. The imaging studies are significant for multilevel cervical degenerative disc disease and neuroforaminal stenosis. It is difficult to determine the true pathology of the patients chronic pain. The medical literature shows evidence for diagnostic facet injections in supporting treatment for facet syndrome. There is no indication for repeat injections two to four weeks apart. Seghal and colleagues performed a two-year literature review to update current scientific evidence on the diagnostic utility of facet joint injections. The authors reported that diagnostic injections are used to diagnose facet joint pain because available techniques cannot identify the pain generators in patients with chronic spinal pain. However, facet joint injections are used to determine if pain is arising from these joints, distinguishing painful from non-painful joints, and for determining response to therapeutic facet joint interventions. The evidence obtained from the literature review suggests that controlled comparative local anesthetic blocks of facet joints are reproducible, reasonably accurate and safe. Novack and Nemeth performed a literature review to determine the current evidence to support guidelines for frequency and timing of epidural steroid injections. The authors found that there was limited evidence to suggest guidelines for frequency and timing of epidural steroid injections or to help define what constitutes the appropriate partial response to support a repeat injection. Abdi and colleagues performed a systematic review utilizing the criteria established by the Agency for Healthcare Research and Quality (AHRQ) for evaluation of randomized and non-randomized trials and criteria of Cochrane Musculoskeletal Review group for randomized trials. The authors reported that there was moderate evidence for interlaminar epidurals in the cervical spine and limited evidence in the lumbar spine for long-term relief. Given that this patient did not experience long-term relief (greater than three months), or demonstrate reduced use of medications and adjunctive therapy such as physical therapy, heat and ice, following the first epidural steroid injection, a repeat epidural steroid is not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a five-year-old male enrollee has requested speech therapy services for the treatment of the enrollees speech apraxia or motor speech disorder. Findings:  The physician reviewer found that verbal apraxia, or apraxia of speech, is impairment in planning and coordinating movements for speech production. While unstructured spontaneous speech or recitation may be possible in some cases, ability to voluntarily initiate goal-directed speech or imitate speech is impaired. This is a deficit in motor programming and sensorimotor processing at the central level. This type of impairment may be seen in otherwise normally developing children. However, it is a neurological disorder that requires intensive treatment. Communication at all levels may ultimately be impaired in the absence of intervention (Lewis).
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for inpatient hospital services. Merrill and colleagues report that the average length of stay nationwide for the treatment of humeral shaft fractures is three nights. Putnam and colleagues report that patients being treated for humeral shaft fractures often require several days of inpatient hospital stay. In this case, the patient sustained a humeral shaft fracture and remained hospitalized to facilitate early fixation and mobilization. The patients hospital course included pain control, risk stratification for surgery, evaluation and surgery by a specialized surgeon, and postoperative skilled therapy and pain control. Therefore, for inpatient hospital services were medical 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 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 49-year-old female has requested high dose Indium-111 octreotide therapy for treatment of metastatic gastrinoma.   Findings:  Two physician reviewers found that though there is limited data on high dose Indium-111 octreotide in this setting, the patient appears to fulfill criteria for possible benefit with the proposed therapy and has no absolute contraindications. Given the lack of other available treatment options in this case, the proposed therapy has the most potential for benefit.
Appeal type: Experimental/Investigational
Decision: Overturned

A 54-year-old female enrollee requested bilateral whole breast ultrasound for medical evaluation of her dense breasts.  Findings:  Two physician reviewers found that there is sufficient support for the requested services in this clinical setting.  The medical records noted mammographically dense breasts.  In this patients case, bilateral whole breast ultrasound is an appropriate modality for further evaluation.  The rationale is that breast cancer may be missed by mammogram in women with dense breasts.  Therefore, the requested bilateral whole breast ultrasound is likely to be more effective than other methods of evaluation.
Appeal type: Medical Necessity
Decision: Upheld

The patient has requested authorization and coverage for consultation with an infectious disease specialist. The records provided for review do not support an indication for a consultation with an infectious disease specialist. There is no documentation that the patients symptoms are concerning for recurrent urinary tract infection given the normal urinalysis as well as an abdominal CT that did not reveal any urinary tract pathology. The patient has undergone a standard evaluation for infectious disease processes based on his presentation. His primary care provider, a gastroenterologist, and urologist have participated in his care. However, there is no report of fevers or laboratory finding to support the requested consultation. In the medical literature, the primary care providers routinely encounter and treat urinary tract infections, including cystitis and pyelonephritis. 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 internal medicine with subspecialty certification in infectious diseases 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 50-year-old female enrollee has requested a continuous glucose monitoring system (CGMS) for the treatment of her type I diabetes mellitus. Findings:  Three physician reviewers found that although there are no substantial studies to demonstrate the utility of continuous glucose monitoring in preventing severe hypoglycemia, the results of Garg and others suggests that the warning system would have been helpful during the patients hypoglycemic episodes.
Appeal type: Medical Necessity
Decision: Overturned

The patient has requested authorization and coverage for Orthovisc injections, three doses in the left knee. Evidence from systematic reviews and randomized controlled trials indicate that although viscosupplementation may relieve knee pain in some patients with osteoarthritis, data has not established which patients will benefit. Guidelines from the American Academy of Orthopedic Surgeons (AAOS) indicate that the data on safety and efficacy of viscosupplementation remain inconclusive. As such, the AAOS does not currently recommend viscosupplementation as standard treatment for osteoarthritis of the knees. Viscosupplementation is reserved for patients with a history of lasting benefit from prior injections and in cases where the remaining options are limited. In this case, the options are limited to a total knee arthroplasty. The patient has tried and failed other conservative treatments, including failed arthroscopic debridement, analgesics, NSAIDs, intra-articular corticosteroids, and physical therapy without significant benefit. Imaging studies show articular cartilage wear. The provider is requesting viscosupplementation with Orthovisc injections. Therefore, Orthovisc injections, three doses in the left knee, are medically necessary 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

This patient is a 14-year-old female with a history of ulcerative colitis. Specimens were sent to the Prometheus laboratory which included the IBD first step in June 2005 and the metabolite test in August 2005. The patients parents have requested reimbursement for the cost of the laboratory testing.  The Health Plan denied their request based on a determination that the testing at issue was not medically necessary.Currently, the gastroenterology societies do not recommend the routine use of the Prometheus studies.  The gastroenterology community does not recognize the medical necessity of this testing and the value of these analyses is primarily academic.  To fully explore the applicability of thiopurine methyltransferase (TPMT) genotyping and E-6-thioguanine nucleotide (E-6-TGN) and E-6-MMP level analysis for therapeutic drug monitoring, large prospective studies with patient entry at the start of AZA therapy are required. Until the results of such studies are available, the AZA dosage adjustments should be primarily guided by clinical response and blood counts. Metabolite level measurements are only applicable in the identification of non-compliance with the prescribed therapy.Based upon the information set forth above, I have determined the laboratory testing at issue was not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Remicade 5 mg/kg given as an intravenous induction regimen followed by a maintenance regimen. In a systemic review on medical therapies for inflammatory bowel disease, it was found that tumor necrosis factor (TNF) inhibitors, such as infliximab, are strongly recommended based on their efficacy at inducing remission in patients with moderate to severely active symptoms. The American Gastroenterological Associations guidelines for initial treatment of Crohns disease recommend using anti-TNF- drugs, such as infliximab, to induce remission in patients with moderately severe Crohns disease that is refractory to other therapies. The guidelines further recommended anti-TNF monotherapy over no therapy or thiopurine monotherapy, and the continued use of anti-TNF  drugs to maintain remission. Alternatives to anti-TNF therapy, such as immunosuppressants, aminosalicylates, corticosteroids, and antibiotics, were not recommended. In this case, the patient has Crohns disease and has already failed therapy on 6-mercaptopurine. Without treatment, the patient is at risk for complications from Crohns disease, such as fistula, stricture, hospitalization, and need for surgery. Given the current medical literature, the requested medication regimen is medically indicated in this setting. Therefore, Remicade is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested medication regimen 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: Urgent Care
Decision: Upheld

Nature of Statutory Criteria/Case Summary: A enrollee has requested reimbursement for psychiatric emergency services. Findings:  The physician reviewer found that the records provided for review do not demonstrate that the services provided were for treatment of a psychiatric emergency medical condition. The patient was not in active or imminent withdrawals, was not a danger to herself or others, was cognitively intact, capable of caring for herself, and was not gravely disabled. She was medically and psychiatrically stable, and she had completed detoxification. The medication changes made during her stay were minor in nature. She did not require services at this high level of care, and could have returned to ambulatory care. She was appropriately evaluated and there was no evidence of a condition placing her health in serious jeopardy, there was no serious impairment to bodily functions, and there was no serious dysfunction of any bodily organ or part. There was no psychiatric emergency present. Although she was depressed, she was not a danger to herself or others, and was not gravely disabled. Thus, the services she received were not psychiatric emergency medical services. Final Result: The reviewer determined that the services at issue were not necessary for treatment of a psychiatric emergency medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in psychiatry with sub-specialty certification in addiction 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 Harvoni for treatment of his hepatitis C virus (HCV).  Findings:  The physician reviewer found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America (AASSLD/IDSA), all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. While eradication of the patients HCV is medically appropriate, AASSLD/IDSA guidelines recommend Viekira Pak over the Harvoni regimen in treatment of patients who have HCV, genotype 4 and are treatment-naive. No medical rationale supported by current literature is provided to support the use of Harvoni over Viekira Pak.  All told, the medical necessity of the requested Harvoni has not been established.   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 gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 51-year-old female enrollee has requested for physical therapy for treatment of her thoracolumbar fusion for scoliosis and kyphosis. Findings:  The physician reviewer found that the physical therapy notes do not clearly document any objective progress by this patient in the areas of range of motion, strength, functional mobility, or activities of daily living and this patient could have continued and can continue her program independently.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for hyperbaric oxygen treatment. Many guidelines for hyperbaric oxygen treatment and hearing loss have not been updated to reflect the current medical literature and routine practice of hyperbaric oxygen. Studies found that hyperbaric oxygen treatment and combined therapy offered some benefits in hearing improvement. Combined intratympanic steroids and hyperbaric oxygen treatment may result in recovery of hearing, especially in lower frequencies. Hyperbaric oxygen treatment plus existing conventional treatment has also been associated with a better outcome than conventional treatment alone. Hyperbaric oxygen treatment is a safe and beneficial adjuvant therapy for sensorineural hearing loss patients. Hyperbaric oxygen treatment should help improve hearing in many patients unresponsive to initial therapy. Due to risk or long-term or permanent hearing loss, withholding hyperbaric oxygen treatment would be more harmful. The requested hyperbaric oxygen treatment is medically necessary for treatment of this patients sensorineural hearing loss.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 upheld. Credentials/Qualifications: The reviewer is board certified in family practice with sub-specialty certification in undersea and hyperbaric 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

The parent of a 13-year-old male enrollee has requested an MRI of the brain for an evaluation of the enrollees medical condition. Findings:  The physician reviewer found that patients who present with headache without neurological symptoms or pertinent history usually have no abnormal findings on imaging studies.  According to the ACR, patients with headaches and no other clinical symptoms only showed abnormalities on imaging in 0.5% of cases. Therefore, the yield of imaging in patients with non-complicated headaches is very low, and imaging is not usually indicated for this population.  This patient has been diagnosed with migraine-type headaches but has no acute symptoms or neurological or other changes.  There is no specific indication for MRI in this patient at this time.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested Viekira Pak for treatment of his hepatitis C virus (HCV). Findings: The physician reviewer found that per the joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), the recommended regimen for treatment-naive patients with HCV genotype 1a infection includes daily fixed-dose combination of paritaprevir/ritonavir/ombitasvir plus twice-daily dosed dasabuvir and weight-based ribavirin for 12 weeks as a Class I, Level A rating. Paritaprevir/ritonavir/ombitasvir plus dasabuvir and weight-based ribavirin was approved by the U.S. Food and Drug Administration (FDA) for the treatment of HCV genotype 1a infection in treatment-naive patients based on registration trials. The SAPPHIRE-I trial included 322 treatment-naive patients with genotype 1a HCV infection (Feld, et al). The SAPPHIRE-I trial reported a high sustained virologic response (SVR) rate (95.3%) with 12 weeks of paritaprevir/ritonavir/ombitasvir plus dasabuvir and ribavirin (Feld, et al). In addition, the PEARL-IV trial included 305 treatment-naive patients with genotype 1a. Based on the results of these studies, paritaprevir/ritonavir/ombitasvir plus dasabuvir (Viekira Pak) is well-supported as effective therapy for the treatment of chronic hepatitis C, genotype 1a. Accordingly, the request for Viekira Pak is medically necessary for treatment of the patients medical condition.  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: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for morphine for treatment of the enrollee's pain. Findings: The physician reviewer has found that the submitted documentation fails to demonstrate the medical necessity of the requested medication.  This patient is not following the opiate maintenance agreement, and the urine toxicology screens are inconsistent with the prescription.  Therefore, the morphine should not be refilled. Opiate maintenance agreements are an essential part of treatment.  Chou and colleagues documented the dangers of chronic opiate therapy for non-malignant pain and that some of these dangers arise from patients not following the prescription.  The current medical evidence does not support the requested medication in this clinical setting.  All told, morphine is not medically necessary for the 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 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.