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

Nature of Statutory Criteria/Case Summary:   An enrollee has requested the ReWalk robotic exoskeleton system for treatment of her spinal cord injury (paraplegia). Findings:  Three physician reviewers found that per the submitted documentation, robotic exoskeleton systems are intended to enable individuals with spinal cord injury at levels T7 to L5 to perform ambulatory functions with supervision of a specially trained companion in accordance with the user assessment and training certification program. In this case, the patient has a history of spinal cord injury with lower thoracic paraplegia. At this level of injury, the patient should be able to perform all essential activities of daily living at a modified independent wheelchair level, consistent with her spinal cord injury. She would be able to use standard or adapted exercise equipment for upper body strengthening and cardiovascular conditioning. She could be expected to be able to stand and ambulate with the use of conventional lower extremity orthoses potentially at a community level which would be included as standard available therapy. Use of a standing frame and regular standing program could be included in an independent home exercise program. In terms of pressure ulcers, performing regular pressure relief while in her wheelchair is the standard of care and an integral part of spinal cord injury education and ongoing management. Lastly, there is a lack of quality studies comparing the requested device against conventional treatments. In sum, the requested ReWalk robotic exoskeleton system is not likely to be more beneficial over other treatment options. Final Result: Three reviewers determined that the requested device is 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: All three reviewers are board certified in physical medicine and rehabilitation 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: Experimental/Investigational
Decision: Upheld

The parent of a 19-year-old male enrollee has requested the medication Xolair for the treatment of the enrollees allergies. Findings:  Two physician reviewers found that the submitted records do not establish the medical necessity of treatment with Xolair for this patient.  The records provided do not document a diagnosis of moderate to severe persistent asthma with symptoms that are inadequately controlled with standard therapy. There is no documentation of wheezing, coughing, shortness of breath, etc.
Appeal type: Medical Necessity
Decision: Overturned

A forty-four year-old female with primary progressive multiple sclerosis is requesting reimbursement for a power operated vehicle and related accessories. Reviewers Findings:  The reviewing physician found that the submitted clinical records indicate the patient has an impaired ability to ambulate and is unable to push herself up independently from a chair.  The reviewing physician found that the Health Plan denial should overturned.
Appeal type: Medical Necessity
Decision: Upheld

A 44-year-old male enrollee has requested in home physician services for evaluation of his symptoms of feeling sick, dehydrated, and weak.  Findings:  The physician reviewer found that California law defines an emergency medical condition as a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in any of the following: (1) Placing the patients health in serious jeopardy; (2) Serious impairment to bodily functions; (3) Serious dysfunction of any bodily organ or part. The treating physician did not document a need for immediate laboratory tests or recommend any other emergent testing. There is nothing in the documentation provided to suggest that this patients symptoms represented an acute, severe, change in his condition that a prudent layperson would believe would jeopardize his health without immediate care. The patients symptoms did not meet prudent layperson criteria for emergency care. A prudent layperson in the patients circumstances would not reasonably expect the absence of emergency care to jeopardize his or her health.
Appeal type: Medical Necessity
Decision: Upheld

A 50-year-old female enrollee has requested for lumbar laminectomy and spinal fusion at L4-5 with decompression of the left L5 nerve root for treatment of her back pain.       Findings:  The physician reviewer found that fusion at L4-5 is unlikely to be successful given the multiple levels of DDD. Laminectomy will not help the patients back pain.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 16-year-old male enrollee has requested authorization and coverage for magnetic resonance imaging (MRI) of the knee for evaluation of the enrollees right knee pain. Findings:  The physician reviewer found that this patient presents with ongoing right knee pain following a twisting injury.  On physical examination, there was clinical concern of an ACL tear.  It is well documented in the medical literature, that MRI is the imaging exam of choice for evaluation of ACL tears. Miller et al stated [m]agnetic resonance imaging (MRI) is the modality of choice for the imaging evaluation of the knee.  MRI has been noted to have a central role in the diagnostic assessment of ACL and/or meniscal tears (Guenoun, et al.) and has become the gold standard of imaging evaluation of ACL injury (Moore). It is also well documented in the medical literature that other injuries of the knee are associated with ACL tears.  A study by Millett and colleagues, supports the contention that associated injuries are common in young individuals with ACL tears. Furthermore, the data also shows that a delay in surgical treatment was associated with a higher incidence of medial meniscal tears.  The outcome of the right knee MRI will have a direct impact on the treatment plan for this patient. In conclusion, the requested right knee MRI is medically necessary for evaluation of the enrollees medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for skilled nursing care provided. Findings:  The physician reviewer found that skilled nursing care provided was not and is not medically necessary for treatment of the patients medical condition. According to the documentation submitted for review, the patient has function deficits due to a brain tumor (glioblastoma). There is a lack of peer-reviewed literature supporting rehabilitation in this clinical setting. Roberts and colleagues studied intensive rehabilitation for glioblastoma, finding that there was functional benefit but not survival benefit. In this case, the patient has received an adequate trial of skilled nursing care level of care without functional benefit. Thus, the medical documentation provided does not support the medical necessity for continued skilled nursing level of care.Final Result: The reviewer determined that the services at issue were not and 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 physical medicine and rehabilitation 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 64-year-old male has requested past and future coverage for transcranial magnetic stimulation (TMS) therapy for treatment of his major depressive disorder.  Findings:  Two physician reviewers found that the patient was diagnosed with onset of depression approximately 4 years ago. He was treated with various selective serotonin reuptake inhibitors (SSRI) and serotonin norepinephrine reuptake inhibitors (SNRI), antidepressant medications as well as aripiprazole. He reports limited response to oral medications and indicates that daily alcohol and cannabis use calm him. He reports reduced ability to work or enjoy past hobbies and sports. The patients medical history is significant for cardiac bypass surgery and he requires assistance with continuous positive airway pressure (CPAP) mask during sleep. Transcranial magnetic stimulation (TMS) was first introduced as a novel method of non-invasive stimulation of the brain. The peer reviewed medical literature evaluating the outcome of treatment consists of varying reports on the efficacy, especially with regard to the long-term effects and potential side effect profile along with case selection. Gross and colleagues provided an updated meta-analysis of studies related to this treatment modality. The authors concluded that although results are suggestive that TMS has significant antidepressant effects, larger multicenter studies are still necessary and are indeed underway to confirm these trends. From their perspective, such treatment is advantageous but continued trials are required to advance this treatment from the experimental phase into standard therapy. Further, Lam and colleagues reported that for patients with treatment resistant depression, repetitive TMS appears to provide significant benefits in short-term treatment studies. However, the relatively low response and remission rates, short durations of treatment, and the relative lack of systematic follow-up suggest that further studies are needed before TMS can be considered a first-line monotherapy treatment for treatment resistant depression. Gershon and colleagues summary also recommends ongoing systematic testing of this treatment modality. Thus, based on the paucity of scientific data supporting the efficacy and safety of TMS, its use in this patients care is not likely to be more beneficial than standard therapies.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 49-year-old woman who has requested authorization for extended therapy with intravenous antibiotics for treatment of Lyme disease.The medical information provided includes office records from the patients family practitioner and extensive records from a rehabilitation hospital where the patient was managed for six days in early June 2006. The admission physical examination was recorded as normal. Although there is a lengthy list of other medical problems in the record, detailed information about these conditions has not been provided.Information regarding the Lyme disease consists mostly of statements about central nervous system Lyme disease. There is no data to support this diagnosis in the record.  Documentation of negative serologies for Babesia microti [twice] as well as negative Western Blots for Lyme disease are included. Positive tests for Bartonella and Ehrlichia from 2003 are cited in the patients providers letter.The patient has received extensive therapy for central nervous system Lyme disease.   The record documents IV Rocephin from December 2004 through January 2005, three separate courses of 30 days of IV azithromycin, and an additional two weeks in which both drugs were given together.The Health Plan has denied authorization for extended antibiotic therapy and related supplies citing a lack of medical necessity.The patient already received a month of treatment with IV Rocephin in 2004-2005 plus an additional two weeks of therapy with this drug, as well as IV azithromycin in the summer of 2006.  This greatly exceeds the recommended antibiotic therapy for any form of Lyme disease.  She also does not have clear evidence of this or any other infection.The evidence provided does not meet diagnostic criteria for Lyme disease. The CDC approach (screening test followed by Western Blot studies) remains the accepted route to a serological confirmation of Lyme disease. In this case, both the IgM and IgG Western Blots were negative. Even if there was sufficient evidence of Lyme disease, there is no support for more than 30 days of treatment with IV antibiotics.  Indeed, except for documented cardiac or neurological disease, there is no indication for a months treatment with Rocephin. Accordingly, I have determined the requested therapy is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested continued physical therapy visits for treatment of the enrollees left ankle and foot pain.  Findings: The physician reviewer found that based on the documentation submitted for review, continued physical therapy visits have not been established as medically necessary for treatment of the patients medical condition. According to Hawson, physical therapy can be of benefit for foot and ankle injury in an athlete. However, there is limited medical literature addressing the appropriate dosage of physical therapy. The Centers for Medicare and Medicaid Services (CMS) guidelines provide a framework for determination of the need for continued physical services. The CMS guidelines for coverage of outpatient physical therapy state that There must be an expectation that the patients condition will improve significantly in a reasonable (and generally predictable) period of time and that All services provided are to be specific and effective treatments for the patients condition according to accepted standards of medical practice; and the amount, frequency, and duration of the services must be reasonable. In this case, the patient has non-specific pain as the records do not mention an injury or specific tissue pathology. She has been treated with 12 sessions of physical therapy, which is the standard of care duration for musculoskeletal complaints. The patients strength and pain improved with 12 sessions of physical therapy. However, the patient has not shown any improved range of motion. It is not likely for range of motion to improve substantially with additional physical therapy sessions. The Health Plan recommendation for the patient to continue with a home exercise program is medically reasonable and appropriate for this patient. In sum, continued physical therapy visits are not medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the requested therapy 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 physical medicine and rehabilitation 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 50-year-old female enrollee requested a bronchial thermoplasty treatment for medical treatment of her asthma.  Findings:  Two physician reviewers found that there is a paucity of medical literature supporting bronchial thermoplasty as a first-line therapy for patients with persistent asthma.  Iyer and Lim concluded that recent results of the AIR-2 trial raise serious questions about the efficacy of bronchial thermoplasty.  There is also a lack of long-term follow-up data demonstrating improved health outcomes with bronchial thermoplasty over standard therapies.  All told, bronchial thermoplasty was not likely to have been more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Experimental/Investigational
Decision: Overturned

The parent of an eight-year-old male enrollee has requested occupational therapy for treatment of the enrollees poor sensory processing and modulation issues. Findings:  Two physician reviewers found that this patient has had multiple symptoms of attention deficit/hyperactivity disorder.  Stimulant medication has exacerbated a tic disorder. Occupation therapy evaluation indicated avoidance to environmental factors such as wearing underwear and fear of brushing his teeth.  It is medically appropriate to attempt to modify these behaviors, utilizing a sensory modulation technique to slowly desensitize these fears.  There is adequate support in the medical literature demonstrating the efficacy of the requested therapy. Schaaf and Miller reported on the effectiveness of sensory integration therapy for children with multiple presentations.  Miller and colleagues conducted a controlled study of the effectiveness of this therapy.   Although the study by Robert and colleagues is a single case study, in this one studied patient, there was a dramatic improvement in behavior and attention when the child received occupational therapy utilizing the requested techniques.  All told, in this patients case, occupational therapy is likely to be more efficacious than other treatment alternatives.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:The enrollee has requested authorization and coverage for progesterone capsules, testosterone cream and Biest estriol capsules for treatment of the enrollees menopausal symptoms, allergic sensitivities and interstitial cystitis. Findings:  The physician reviewer found that the request for progesterone capsules, testosterone cream and Biest estriol capsules are not medically necessary for treatment of the patients medical condition. According to the American College of Obstetricians and Gynecologists Committee on Gynecologic Practice and the Practice Committee of the American Society for Reproductive Medicine, Evidence is lacking to support superiority claims of compounded bioidentical hormones over conventional menopausal hormone therapy. Practice guidelines further state that Customized compounded hormones pose additional risks. These preparations have variable purity and potency and lack efficacy and safety data. Because of variable bioavailability and bioactivity, both underdosage and overdosage are possible. Conventional hormone therapy is preferred over compounded hormone therapy given the available data. In general, bioidentical hormones are not the standard of care or recommended. Furthermore, there is a lack of sufficient documentation describing the patients past medical, surgical or gynecological history that would support the medical necessity for alternative therapy. Final Result: The reviewer determined that the requested medications are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in obstetrics and gynecology 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 10-year-old male who has a probable diagnosis of Aspergers syndrome with Learning Disability and ADD/ADHD.  He has been treated with stimulants for over two years and his parents report that weight loss and serious side effects occurred.  A trial of a non-stimulant medication resulted in paranoia. The parents state that the patient needs medication for the symptoms of ADD/ADHD and Provigil was tried in an off-label application and found to be effective. The parents have requested authorization for continued treatment with Provigil. The Health Plan denied their request based upon a determination that the medication is not medically necessary.It is not uncommon to find symptoms of ADD or ADHD in a child with a possible diagnosis of Aspergers syndrome. The majority of these children respond to stimulant medication or a combination of stimulant medication and other medications such as Tenex or Clonidine.  As with this patient, the use of Strattera is often complicated by side effects and is not recommended as the treatment of first choice.  Stimulant side effects can usually be controlled by modification of the drug dosage.  The off-label use of a medication such as Provigil that has not been found to be safe or efficacious in this setting, is not the standard of care in the community.  Therefore, I have determined the requested medication is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

A 44-year-old female enrollee requested authorization and coverage for thigh lift surgery for removal of redundant skin pursuant to successful bariatric surgery. The health plan has denied this procedure on the basis that it is considered cosmetic and is not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the health plans denial on the basis that the requested procedure is reconstructive in nature and is medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

A 63-year-old female enrollee has requested spinal fusion surgery for treatment of her lower back pain.  Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the procedure at issue. Milliman Care Guidelines indicate that surgery may be considered reasonably necessary for patients who have spondylolisthesis with persistent and significant symptomatic discomfort despite an adequate trial of at least 6 months of conservative care. Prior to surgery conservative measures that can be attempted include medication management with nonsteroid anti-inflammatory drugs (NSAIDs) or analgesics, physical therapy to improve strength and range of motion (for at least a trial of four weeks), activity modification and interventional injections if radiculopathy or facet disease is present. In the case of this patient, there is a lack of documentation of recent, significant conservative care prior to undergoing surgery. Furthermore, there is no instability on flexion or extension views. Given that the patient had no documented spinal instability, it would not be appropriate to proceed with fusion without a recent, more exhaustive and more sustained attempt at conservative measures, including physical therapy. Although the provider indicates that the patient has had physical therapy over the years, there is no evidence that she received physical therapy within three years of the fusion procedure. In the absence of documented spinal instability as well as a lack of evidence that adequate conservative measures were exhausted prior to surgery, the medical necessity of spinal fusion surgery is not established.