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

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Nucynta ER tablets for treatment of his medical condition.   Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication.  The current standard of care for chronic pain is treatment in a multidisciplinary practice to include physical therapy, massage therapy, cognitive behavioral therapy, and injections to help reduce pain.  Researchers reported that high-dose opiates may contribute to pain sensitization via opioid-induced hyperalgesia, decreasing patient pain threshold and potentially masking resolution of a preexisting pain condition.  High-dose opiates may cause adverse outcomes.  The aim of current guidelines is to protect patients from the adverse effects of opioid therapy.  All told, the requested medication is not medically indicated 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.
Appeal type: Experimental/Investigational
Decision: Upheld

A 53-year-old male enrollee has requested for percutaneous discectomy (nucleoplasty) for treatment of his L3-L4 herniation and low back pain.  Findings:  Three physician reviewers found that there is not adequate scientific data consisting of randomized, controlled large sample studies to show the efficacy of nucleoplasty. There are no comparative studies showing the safety and long-term effectiveness of nucleoplasty. The review by Manchikanti and colleagues only found level III evidence (lacking direct evidence) of the effectiveness of the procedure. Thus, based on the available scientific data, the superiority of nucleoplasty in this clinical setting has not been established.
Appeal type: Urgent Care
Decision: Upheld

A female enrollee requested medical services provided on an emergent or urgently needed basis.  Findings:  The physician reviewer found that nonsurgical management of metacarpal fractures includes buddy strapping of the injured digit to the neighboring digit and splinting or casting.  There was no documentation of a significant functional deficit or acute or severe pain. In sum, the patient was not suffering from an acute illness that was likely to place the patients health in serious jeopardy, cause serious impairment to body functions or cause series dysfunction to a body organ or part. Therefore, the patients symptoms did not meet prudent layperson criteria for emergency care.  Further, it has not been established that criteria for urgently needed services were met. The services could have been delayed until the patient returned to her Health Plans service area. Based on the medical records submitted for review, there was no indication that a prudent layperson in a similar situation would have believed immediate medical attention was necessary to prevent serious deterioration of ones health. Further, there was no evidence that her condition was deteriorating. In sum, based on the patients clinical presentation, she did not meet prudent layperson criteria for urgently needed services.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a two-year-old male enrollee has requested for speech therapy for treatment of the enrollees speech delay.  Findings:  The physician reviewer found that as speech therapy is recommended for young patients with speech delay, the primary goal of treatment is to give the patient a reliable way to exchange ideas and information in his or her daily social and educational environment. Treatment is tailored to the specific communication needs of each patient, which vary with disorder type and severity, age, and the etiology of the condition. This patients evaluation revealed a severe language expression delay that needs to be treated with the recommended speech and language therapy. Speech therapy is the standard of care for patients with speech delay and therefore is medically necessary for this patient.
Appeal type: Medical Necessity
Decision: Overturned

The mother of a four-year-old male enrollee requested authorization and coverage of continued speech therapy. The Health Plan denied the request indicating that the requested therapy is not medically necessary for treatment of the enrollees speech delay.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plans denial on the basis that the requested therapy is medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

An 18-year-old male enrollee has requested laboratory testing for evaluation of her multiple medical conditions.  Findings:  The physician reviewer found that  There is no peer-reviewed evidence scientific evidence to support the efficacy of this testing at this time. The physician reviewer found that there is no peer-reviewed data demonstrating that such testing has any clinical utility in this setting. Therefore, Realtime Labs  urine mycotoxin panel is not medically necessary for this patient.
Appeal type: Medical Necessity
Decision: Upheld

The parents of a three-year-old female with speech production delay are requesting authorization for previous and future speech therapy.  There is no medical information demonstrating a clinical rationale for the patients delay has been provided.Reviewers Findings:  The reviewing physician found that there is no evidence that speech therapy for a three-year-old with a speech delay without an associated medical diagnosis is medically necessary.  The reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 53-year-old male with a history of profound hearing loss bilaterally, status post placement of cochlear implant in 1994. The patients current external processor was repaired in March 2004. It is reportedly functioning satisfactorily. The patient is requesting an ESPrit 3G, which is a new external processor that offers some advantages over its predecessor. The Health Plan has denied authorization for an ESPrit 3G speech processor on the basis that it is not medically necessary.Though the new ESPrit 3G external cochlear implant processor is more sophisticated than the patients current processor, it is not paramount to the function of the cochlear implant. Furthermore, the submitted evidence indicates the patients current processor is functional and working effectively. There is no indication the ESPrit 3G processor will improve the patients function. As such, there is no medical indication for use of the ESPrit 3G processor at this time. Therefore, I have determined that the requested equipment is not medically necessary for the treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

A 39-year-old female enrollee requested authorization and coverage of a brain SPECT scan to confirm diagnosis of depression, anxiety and attention deficit disorder.  The health plan denied the enrolleeS request indicating that the requested scan is not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer upheld the health plans denial on the basis that the requested SPECT scan is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for physical therapy services, including aqua therapy, cold therapy, and land therapy, within a 10-minute drive of the patients home address. Researchers report on the benefits of exercise for chronic pain in the setting of fibromyalgia. Researchers report that physical activity and exercise in the setting of chronic pain showed some favorable effects in reduction in pain severity and improved physical function. Researchers note that exercises in general, and specifically aquatic exercises, are beneficial for reducing pain and disability in many musculoskeletal conditions. However, there is a lack of evidence in current medical literature that formal aqua therapy programs result in marginally superior pain, health, or functional outcomes over water-based exercises that are pursued independently or performed in informal group exercise settings. In comparing AquaStretch, a form of assisted stretching in water, to supervised land based stretching for patients with chronic low back pain, Keane concluded that AquaStretch had key additional benefits including time efficiency, cost effectiveness and the ability to be performed by qualified individuals other than physiotherapists. Formal aquatic therapy, as opposed to generalized water-based exercise, is medically indicated only in specific circumstances, such as for patients who require therapy in a partially body weight unloaded environment and who are unable to perform the applicable exercises safely without formal therapist guidance, instruction and supervision. In this case, the patient has chronic, generalized pain, and has already undergone extensive physical therapy without significant, durable benefit. Due to her persistent symptoms, she underwent recent right hip surgery. The records do not document impairments that would preclude exercises and modalities on an independent basis, including self-applied, self-administered, passive, or palliative measures. Given that no marginal difference in clinical outcomes is expected under an independent program over continued formal physical therapy, whether aquatic or land-based, the requested services are not medically indicated. Therefore, physical therapy services, including aqua therapy, cold therapy, and land therapy, within a 10-minute drive of the patients home address are not medically necessary 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 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: Medical Necessity
Decision: Upheld

The patient has a long history of rosacea. In this note, the patient admitted to excessive sun exposure. She had used Metrogel (metronidazole) 0.75% topical gel in the past with good results. Rosacea is a chronic condition that is treated with patient education, skin care techniques, and pharmacologic interventions. Patient education regarding trigger avoidance and skin care techniques such as moisturizing and sun protection are important non-pharmacologic first steps in treating rosacea. Pharmacologic interventions range from topical to systemic medications depending on the symptoms and severity of each patient. In this case, the patients rosacea is described as mild in severity. There are no indications that she has followed patient education regarding trigger avoidance and skin care techniques. Further, she admits to excessive sun exposure. Therefore, the requested Metrogel 0.75% topical gel is not medically necessary to treat this patient's medical condition.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 dermatology 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: The parent of an enrollee has requested authorization and coverage for Dupixent. The records provided for review document that this patient presented with moderate-to-severe atopic dermatitis. The patient has tried and failed therapy with topical steroids and Eucrisa. The medical records document the presence of side effects with topical steroid therapy. Dupixent is U.S. Food and Drug Administration (FDA) approved for the treatment of asthma in patients 12 years of age and older and adults with moderate-to-severe atopic dermatitis. The medical documentation reports that this patient has moderate-to-severe psoriasis and adverse effects from topical steroid use. As the FDA approval for Dupixent in patients aged 12 years and older is in place for asthma, the medication is deemed safe in this age group. Moreover, there are ongoing trials examining the use of Dupixent in the adolescent age group with positive results reported in the literature. For these reasons, Dupixent is more likely to be more effective for treatment of this patients moderate-to-severe atopic dermatitis than other alternative therapies.Final Result: Two of the three reviewers determined that the requested medication is 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:  One reviewer is board certified in dermatology and is actively practicing. One Reviewer is board certified in dermatology and is actively practicing.  One Reviewer is board certified in dermatology and is 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: Overturned

The parent of a two-year-old female enrollee has requested one hour per week of speech therapy and one hour per week of sensory integration focused occupational therapy for treatment of the enrollees autism. Findings:  The physician reviewer found that with regard to the requested speech therapy, Eikeseth noted that the goal of early identification of speech and language problems is to initiate early intervention, which has been shown to improve outcomes for children who have autism. On average, the young patients who received the behavioral treatment gained 17 IQ points, 13 points in language comprehension, and 23 points in expressive language and 11 points in adaptive behaviors. In comparison, the eclectic treatment group obtained an average of +4 points in IQ, and made no further gains. Given this patients diagnosis of significant speech and language delay related to autistic spectrum disorder, she is an appropriate candidate for speech therapy services. The requested one hour per week of speech therapy is a medically necessary intervention for this patient. Further, concerning the request for occupational therapy utilizing sensory integration, the AAN and CNS indicate that evaluation of sensorimotor skills by a qualified experienced professional (occupational therapist or physical therapist) should be considered, including assessment of gross and fine motor skills, praxis, sensory processing abilities, unusual or stereotyped mannerisms, and the impact of these components on the autistic persons life. In general, an occupational therapy evaluation is indicated when Deficits exist in functional skills or occupational performance in the areas of play or leisure, self-maintenance through activities of daily living, or productive school and work tasks. To support the need for occupational therapy, studies have shown benefits that prevents a deterioration or reversal of function and a significant improvement in activities of daily living, (Case-Smith, et al). Another example of a patients own account of how occupational therapy improved his activities of daily living (ADLs) over a five-year period was documented by Shoener. In this patients case, the records support the existence of a slight but definite improvement with occupational therapy. Treatment with occupational therapy utilizing sensory integration is medically reasonable and appropriate in this case. The requested one hour per week of occupational therapy with sensory integration is a medically necessary service for this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for FoundationOne gene test for treatment of the enrollees colon cancer.Findings: Three physician reviewers found that there is a lack of support for the services at issue in this clinical setting.  FoundationOne is a molecular assay that explores the mutations of an individuals cancer cells. The hope is that the assay will identify a specific mutation or target, which could inform the clinician as to which chemotherapeutic agent would be useful. However, there is a lack of convincing evidence that the assay adds to the decision making ability of the clinician, nor yields a result that is reliably clinically beneficial, (Von Hoff, et al). There are various nonrandomized studies exploring the value of molecular profiling but these studies are not convincing as to its efficacy.  A randomized study by Le Tourneau and colleagues did not demonstrate significant clinical benefit from choosing therapy based on molecular targets. Additionally, recent studies have expressed reservations about this approach in general. In sum, FoundationOne gene test was not likely to have been of greater clinical benefit over the standard options available for the evaluation of this patients medical condition.Final Result: The 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 medical oncology 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 61-year-old male enrollee has requested total ankle replacement surgery for the treatment of his right ankle pain. Findings:  Two physician reviewers found that the scientific literature reveals adequate outcome data to support the efficacy of total ankle replacement. The data demonstrates the procedure preserves mobility in the ankle over fusion and is safe and effective in the long-term. In addition, this patients clinical presentation lends to the conclusion that he will likely benefit from total ankle replacement surgery, especially after failing to receive long-term benefit from the earlier procedures. Therefore, considering the current orthopedic standard of practice this patient is an appropriate candidate for total ankle replacement and the procedure is likely to be more beneficial for the treatment of the patients right ankle arthritic condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld

A 54-year-old male enrollee has requested Saunders Cervical Hometrac Deluxe device for treatment of his degenerative disc disease at C4-5 and C6-7. Findings:  The physician reviewer found that this patients records do not establish that the traction provided in PT resulted in any significant, sustained symptomatic relief, or functional benefit. The patient was receiving multiple concomitant therapeutic interventions and therefore it is not clear which, if any, modality was responsible for any symptom relief that may have occurred during the course of therapy. Furthermore, it is not evident how much of the patients symptomatic improvement was due to active interventions and not just part of the natural course of a waxing and waning pain syndrome. Finally, the requested device would not be expected to significantly alter the need for any future surgery that may be indicated for his cervical spine. For these reasons, given the limitations of the extant published literature the requested device is not within the standard of care and therefore not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 58-year-old male enrollee has requested Cialis for the treatment of his erectile dysfunction.  Findings:  The physician reviewer found that it is well documented that 33% of men in their 50s and 50% of men in their 60s have some degree of failure to obtain or maintain an erection. This is thought to be due to early atherosclerotic changes that develop in the small arterioles before lesions are demonstrated in the larger vessels, which are easier to document. Those who are partially impaired are most likely to get an excellent clinical response with Cialis or one of the other 5 PDE inhibitors. In this case, the patient reports his best response is to Cialis. The use of Cialis in this setting is very appropriate and clinically indicated.
Appeal type: Medical Necessity
Decision: Upheld

A 57-year-old female enrollee has requested for spinal fusion surgery for treatment of her L4 to S1 spondylosis and discogenic low back pain. Findings:  The physician reviewer found that there is no instability, no significant degeneration, and she has had no previous spinal procedures.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  The parent of an enrollee requested residential behavioral health treatment services for treatment of her post-traumatic stress disorder (PTSD), trichotillomania, and mood disorder.  Findings:  The physician reviewer found that the provided progress notes do not provide adequate documentation to support the medical necessity of 24-hour daily medical or nursing treatment for this patient. The psychiatric notes fail to indicate any concerns of dangerous behavior, such as thoughts of harming self or others, any psychosis, or significant impairment in ability to function. Specifically, these are issues commonly treated on an outpatient basis and do not require the services of a residential treatment center. Thus, the residential behavioral health treatment services in question were not and are not medically necessary for treatment of this patients medical condition. 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 psychiatry with sub-specialty certification in child and adolescent psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.