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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for acupuncture services two times a week for six to twelve weeks.Clinical Practice guidelines from the American College of Physicians state that for patients with chronic low back pain, clinicians and patients should initially select nonpharmacologic treatment. The guidelines include acupuncture among their specified nonpharmacologic treatments. Vickers and colleagues have also noted that acupuncture is effective for the treatment of chronic musculoskeletal pain. Peer reviewed literature recommends an initial trial of six acupuncture appointments in combination with a conditioning program of aerobic and strengthening exercises. Future acupuncture appointments should be tied to improvements in objective measures to justify an additional six sessions. Clear evidence of objective functional improvement (quantifiable response to treatment) should be established in future exams if more care is requested. Significant objective benefits include a decrease of pain (Visual Analog Scale), increased endurance, increased body mechanics and ability to perform ADLs (activities of daily living), increased ability to perform job-related duties, improved sleep or reduced pain behaviors, amongst others.In this case, the patient has been diagnosed with chronic myofascial pain and suffers from chronic neck, shoulder and back pain. Records reflect that the patient underwent prior acupuncture sessions with benefits. As the patient continues to be symptomatic despite prior procedures, an acupuncture trial for pain management and function improvement would be reasonable at this time. However, the submitted records do not include any extraordinary circumstances that warrant exceeding the practice of an initial trial of six acupuncture sessions, with future acupuncture appointments tied to improvements in objective measures to justify additional sessions. Accordingly, while the requested acupuncture services two times a week for six to twelve weeks are not medically necessary to treat the patients medical condition, an initial trial of six sessions of acupuncture services is medically necessary to treat the patients medical condition.Final Result: The reviewer determined that a portion of the requested services are medically necessary to treat the patients medical condition. Therefore, the Health Plans denial should be partially overturned.Credentials/Qualifications: The reviewer is a licensed acupuncturist, board certified in oriental medicine, and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 21-year-old female has requested coverage for past residential treatment services provided for treatment of her substance abuse, anxiety, and depression.   Findings:  The physician reviewer found that based on review of the available records, this is a difficult patient to treat actively as she has a significant personality disorder which generally results in poor treatment outcomes. Longer inpatient stays do not necessarily translate into better outcomes, but rather further regressions. In some cases, repeated short-term acute admissions are indicated and the course is long and symptom-based. There is some data to suggest outpatient group and individual dialectical behavioral therapy (DBT) oriented treatment provides better prognosis in the long-term. Consistent with the American Psychiatric Association (APA) treatment guidelines, the residential stay at issue did not offer sufficient expectation of improvement to be supported as medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

A 50-year-old male enrollee has requested bilateral knee Hyalgan injections for the treatment of his chondromalacia and osteoarthritis. Findings:  The physician reviewer found that this patient has not tried a number of medications which might be helpful. In addition, the patient has not tried topical modalities. The Health Plan's requirement for a trial of intra-articular steroids is not unreasonable, as these may be effective. Given that there are a number of alternatives, the use of Hyalgan is not medically necessary at this time for the patients bilateral knee condition.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a 14-year-old male enrollee has requested authorization and coverage for treatment of the enrollee diagnose with attention deficit/hyperactivity disorder and Tourettes syndrome. Findings:  The physician reviewer found that that treatment of comorbid attention deficit/hyperactivity disorder has been controversial due to reports that stimulants hasten the onset or increase the severity of tics in some patients. This is not necessarily a contraindication for stimulant treatment in patients with significant symptoms of attention deficit/hyperactivity disorder.  A stimulant in combination with either clonidine or guanfacine, or with a neuroleptic agent may be beneficial in this clinical setting.
Appeal type: Medical Necessity
Decision: Upheld

A 41-year-old female enrollee requested authorization and coverage of a revision panniculectomy. The Health Plan denied the request indicating that the requested procedure is not medically necessary for treatment of the enrollees abdominal tissue.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested procedure is not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for weekly acupuncture for two to three months. On review of the available documentation, this patient presents with interstitial cystitis. The patient has undergone treatment with physical therapy, medications, as well as modifications in her diet without adequate relief of her symptoms. The patients provider has recommended treatment with acupuncture. The current peer-reviewed medical literature supports a trial of acupuncture to address this patients interstitial cystitis. Medical literatures reported that, Therapies with the potential for benefit in patients with bladder pain syndrome are dietary management, acupuncture and physical therapy. The authors noted that complementary alternative medicines for patients with interstitial cystitis can include acupuncture. Researchers found that the results of their study support that acupuncture is an effective, useful, non-invasive method in patients with interstitial cystitis. In reviewing the available documentation, the records do not indicate that the patient has undergone an acupuncture trial. Given the patients pain levels despite prior treatment modalities, an acupuncture trial for pain management and function improvement is appropriate. Overall, the medical literature supports treatment with acupuncture for 12 once weekly sessions given this patients diagnosis of interstitial cystitis. For these reasons, the requested once weekly acupuncture for three months is medically necessary for 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 a licensed L.Ac., board certified in oriental medicine and acupuncture, 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

The patient is a 17-year-old female with a history of multiple surgical procedures, orthodontic therapy, and speech therapy for bilateral cleft lip and cleft maxillary alveolus. Currently, the patient has a dental malocclusion, maxillary deformity with asymmetry, and absent dentition in the region of the alveolar clefts. A request has been made for authorization and coverage for repositioning surgery of the upper jaw. The Health Plan has denied the request on the basis that the requested surgery is not medically necessary.Maxillary osteotomies and bone graft are proposed for staged reconstruction of the patients maxilla with complete bilateral alveolar clefts. Closing and grafting the clefts will eventually allow dental arch reconstruction with dental implants. The proposed orthognathic surgery is the most appropriate next step for this patient in the sequence of reconstructive events and is medically indicated. Therefore, I have determined that the requested surgery is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Rituxan (rituximab). Findings: The American College of Rheumatology guidelines for the screening, treatment, and management of lupus nephritis, note that Rituxan may be used for the treatment of lupus nephritis when other standard treatments, such as Cellcept or Imuran, fail. In this case, given that the records indicate that the patient has a diagnosis of systemic lupus erythematosus (SLE) and hemolytic anemia, and has been unable to tolerate or had poor treatment response to standard therapies for  SLE, including Imuran and Cellcept, the requested medication is medically indicated. Therefore, Rituxan (rituximab) is medically necessary for the treatment of this patient.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 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: Overturned

Nature of Statutory Criteria/Case Summary:   An enrollee has requested a 12 week course of Harvoni for treatment of his hepatitis C virus (HCV). Findings:  The physician reviewer found that the submitted documentation establishes the medical necessity of the requested medication. In this case, the patient meets American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) guidelines for immediate HCV eradication with the highest priority.  The patient is currently being treated with medication that is contraindicated with the concurrent use of Harvoni.  Per the Drugs.com, drug interaction between this medication and dasabuvir (Viekira) are noted as a Major interaction. However, interaction between this medication and sofosbuvir (Harvoni) are noted as a Moderate interaction. The benefit of treatment for HCV with Harvoni with moderate interaction outweighs non-treatment. Given that Harvoni and this medication have a Moderate interaction, Harvoni for 12 weeks is medically necessary for this patient. 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 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested breast tomosynthesis for evaluation of her medical condition. Findings: Three physician reviewers found that tomosynthesis is a technique that was developed as a problem solving adjunct to routine mammography.  In addition, any mass could possibly be better characterized with tomosynthesis. Given the reasons above,  breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.  Final Result: All three reviewers determined that the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: All three reviewers are board certified in diagnostic radiology 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Lantus insulin in a pen formulation.Since the introduction of insulin as a life-saving agent for patients with type 1 diabetes, insulin preparations have evolved to approximate physiologic insulin delivery profiles to meet prandial and basal insulin needs. Basal insulins, such as Lantus, are designed to have a protracted time-action profile to facilitate basal glucose control over 24 hours. Though many patients with type 2 diabetes can manage their condition with oral agents, initiating insulin therapy with a basal insulin analogue has become a standard of care in the treatment of type 2 diabetes mellitus. While most patients use prefilled insulin pens to administer Lantus (and other insulins), it is also available to be administered from a vial with a syringe. Medical literatures have shown that using an insulin pen device is associated with increased therapy persistence and adherence, and lower hemoglobin A1C levels relative to vial/syringe, without increasing total all-cause or diabetes-related costs. In this patients case, the pen is even more important, as she is required to travel to high human traffic areas where there are developmentally disabled children and adults, and a pen is therefore a much safer option. Under these circumstances, the requested Lantus insulin in a pen formulation is medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested medication is medically necessary to treat the patients medical condition. Therefore, the Health Plans denials should be overturned.Credentials/Qualifications: The reviewer is board certified in internal medicine, with subspecialty certification in endocrinology, diabetes, and metabolism, 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: The patient has requested authorization and coverage for Botox injections in the jaw. The American Academy of Neurology (AAN) recently updated its guidelines on using Botox in the treatment of brain disorders (Simpson, et al.). Botox is now recommended for the management of chronic migraine, defined as attacks lasting four or more hours on at least 15 days each month for three months. Botox has been demonstrated to be safe and effective to increase headache-free days and improve health-related quality of life in chronic migraine. Frampton and Silberstein reviewed the current evidence on Botox in the prevention of chronic migraine. The authors found that the data suggests that Botox is an effective and generally well tolerated option for the prevention of chronic migraines that may be particularly useful for patients who have previously failed to respond to or are intolerant of oral prophylactics (Frampton and Silberstein). Moreover, Kocaman and colleagues suggested that Botox may also be effective in the treatment of temporomandibular disorder (TMD). The authors found that the patients with a diagnosis of chronic migraine and concomitant TMD reported a decrease in temporomandibular junction pain as well as a decrease in myalgia and headache after Botox treatment. In this case, the patient has a history of chronic migraines that has not responded to oral preventative medications and TMD. Based on the current medical literature, TMD can be a risk factor in migraine progression. Treatment with Botox is an effective prophylactic treatment for treatment of this patients chronic migraines and TMD. Therefore, the requested Botox injections in the jaw are medically necessary for 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 neurology 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 29-year-old female enrollee requested authorization and coverage Of Botox therapy. The Health Plan denied the request indicating that the requested therapy is considered investigational for treatment of the enrollees migraine headaches. Three physician reviewers performed an experimental/investigational Independent Medical Review. Two physician reviewers concluded that the requested therapy is likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy. One  physician reviewer concluded that the requested therapy is not likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy. Because two of the three physician reviewers concluded that the requested therapy is likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy, the Health Plans denial has been overturned.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a two-year-old male enrollee has requested one hour of speech therapy, twice per week, and one hour per week of occupational therapy services for treatment of the enrollees deficits in fine motor skills and delays in receptive language, expressive language and pragmatic skills.  Findings:  The physician reviewer found that approximately 5% of preschool children will exhibit speech and language delay. There is evidence indicating that preschool children with developmental speech and language disorders are at increased risk for difficulty with reading when they enter school.  A 2004 systematic review by Law and colleagues determined that speech and language therapy might be effective for children with phonological or expressive vocabulary difficulties. Studies have reported an overall positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulties.  In this case, the evaluation of his speech and language function on the said date showed global issues in speech delay.  Thus, in this patients case, one hour per week of speech therapy services is medically indicated. However, the submitted documentation fails to establish the medical necessity of occupational therapy. There are conflicting reports about his developmental skills, particularly as it relates to motor delay.  Furthermore, the patient has maintained his weight, and there is no particular documentation of oral-motor aversion.  Per the submitted records, he does not meet the criteria for a sensory feeding disorder.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested breast tomosynthesis for evaluation of her medical condition.   Findings:  Two physician reviewers found that digital breast tomosynthesis was approved by the U.S. Food and Drug Administration (FDA) for clinical. Despite the lack of long-term studies proving an increased survival rate when tomosynthesis has been used as part of screening mammography, the American College of Radiology (ACR) subsequently urged the technique be removed from the investigational category due to the advantages this new tomographic technique brings to radiologists interpreting mammograms. Accordingly, breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.  Final Result: Two reviewers determined that the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: All three reviewers are board certified in diagnostic radiology 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.