Persius/imr-appeals huggingface dataset:
Appeal type: Urgent Care
Decision: Upheld

A 59-year-old male enrollee has requested emergency services for the treatment of his abdominal pain. Findings:  The physician reviewer found that the patient had a history of chronic left lower quadrant abdominal pain that was exacerbated over the previous three weeks. He rated the pain level in the ED as 7/10. The patients symptoms did not meet prudent layperson criteria for emergency care. A prudent layperson with an average knowledge of medicine and chronic abdominal pain increasing to a level of 7/10 over a three-week period, without any other associated symptoms, would not reasonably expect the absence of emergency care to jeopardize their health. Although this patient states in his appeal letter that his pain had become unbearable on that day, the medical record is not consistent with that claim and described moderate pain, chronic in nature. Based on the patients symptoms as described in the medical record, his evaluation could have safely occurred on a non-emergent basis.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: A enrollee has requested reimbursement for a dental procedure (D7953) performed on 11/30/16 for treatment of the enrollees dental condition.  Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the services at issue. D7953 is a benefit to rebuild the bone after an extraction. This patient presented with a dehiscence or cleft in the bone of the tooth socket at extraction, with periodontal probe depths of 6 to 11 mm.  In this setting of loss of bone as described, the literature shows a bone graft to be an effective means of preserving or restoring the bone to the extraction site to allow placement of an implant.  The documentation indicates that implant support may have been compromised without the procedure. Therefore, dental procedure (D7953) performed on 11/30/16 was medically 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 dentistry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a bone growth stimulator for treatment of the enrollees delayed union of fracture. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested device. Current evidence-based guidelines recommend ultrasound bone growth stimulation as an option for delayed or non-union of fractures, especially with significant associated risk factors. Specific indications include at least three months have elapsed since the date of fracture and the initiation of conventional fracture treatments, serial x-rays have confirmed that no progressive signs of healing have occurred, the fracture gap is one centimeter or less, and the fracture is adequately immobilized. Risk factors include diabetes, osteoporosis, steroid therapy, current smoking, or fractures with extensive soft tissue or vascular damage. This patient presents with complaints of diffuse left foot and ankle pain. She reportedly sustained a left fifth metatarsal fracture in late September 2016. Pain was reported in weight-bearing activities. There is reported x-ray evidence of delayed union of her left foot fifth metatarsal fracture. However, there is no documentation of serial x-rays showing no progressive signs of healing or current fracture gap. There is no documentation of adequate immobilization or discussion of conventional fracture treatments. Therefore, the requested bone growth stimulator is not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested device 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 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: Overturned

The parent of a two-year-old male enrollee has requested speech therapy (one day per week, one hour per session for treatment of the enrollees severe expressive language delay.  Findings:  The physician reviewer found that as noted by Nelson and colleagues, speech and language development is considered by experts to be a useful indicator of a childs overall development and cognitive ability and is related to school success. The authors noted that identification of children at risk for developmental delay or related problems may lead to intervention services and family assistance at a young age when chances for improvement are best.  Speech and language delay must be taken seriously in young children, because the long-term consequences may be substantial. According to Law and colleagues, approximately 6% of children have speech and language difficulties. The authors noted that children whose difficulties persist into primary school may have long-term problems concerning literacy, socialization, behavior, and school attainment.  Bernhardt and Major concluded that early phonological and metaphonological intervention can promote normalization of speech development and normal acquisition of literacy skills for some children with a history of severe phonological impairment.  This patient has severe expressive language delay that is significantly impairing his ability to communicate effectively.  The current medical evidence supports the requested speech therapy in this clinical scenario.  All told, speech therapy, at a frequency of one day per week, one hour per session, is medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Overturned

A female enrollee requested three-dimensional x-ray (digital breast tomosynthesis for medical evaluation of the enrollee, who has a family history of breast cancer.  Findings:  Three physician reviewers found that the current medical evidence supports the services at issue in this clinical setting.  The scientific data has shown the advantage of adding three-dimensional breast tomosynthesis to the usual two-dimensional full field digital mammographic images.  This technique has been particularly useful in patients with dense breast tissue, and the current data shows a decrease in recall rate and increased sensitivity to the early detection of cancer.  Thus, the three-dimensional x-ray (digital breast tomosynthesis) was likely to have been of greater benefit than other methods of evaluation.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for home speech therapy services. The patient has a demonstrated developmental language disorder. Given the patients age, intervention with a speech pathologist will have significantly more efficacy when the developing brain has more neuroplasticity. Speech and language interventions result in maximal gains during this critical period of neuroplasticity. However, children with developmental language disorder are at significantly greater risk for emotional reactivity. Adding extended travel time to obtain speech and language services is at odds with trying to achieve maximum benefits. Given these findings, the requested home speech therapy services 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 with special qualification in child 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: Upheld

A 19-year-old female enrollee has requested reimbursement and prospective authorization and coverage for intravenous antibiotic treatment using azithromycin from a specific date and forward for treatment of the enrollee, who has a stated diagnosis of Lyme disease. Findings:  Three physician reviewers found that the patient has multiple symptoms that started approximately when she was 12.  These symptoms include nausea, weight loss, fatigue, tachycardia, confusion, depression, hair loss, and joint pain.  The medical records show equivocal Western blot tests for Lyme, and cerebrospinal fluid analysis was not submitted for review.  The patient has requested reimbursement and prospective authorization and coverage for intravenous antibiotic treatment using azithromycin.  The Health Plan has denied this request as investigational for the treatment of this patient. In this patients case, the superior efficacy of the therapy at issue has not been established.  The current medical evidence does not support the requested intravenous antibiotic treatment in this clinical setting.  The submitted medical records do not establish the diagnosis of Lyme disease.  Additionally, for patients with Lyme disease, over one month of intravenous therapy is not more effective than a shorter treatment course.  Continued use of long-term antibiotics is not likely to be beneficial in this case.  All told, intravenous antibiotic treatment using azithromycin from the date in question and forward was not and is not likely to be more efficacious than other available treatment modalities.
Appeal type: Medical Necessity
Decision: Upheld

A 46-year-old female enrollee has requested for MRI of the thoracic and cervical spine for evaluation of her back pain. Findings:  The physician reviewer found that while the MRI of the lumbar spine was reasonable based on the severity of the patients pain and positive SLR, there were no findings that warranted cervical or thoracic MRI. Further, the MRI of the brain that is said to have diagnosed MS was done several months after the thoracic and cervical MRIs indicating these studies were not performed to look for evidence of spinal involvement of MS.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested a 24 week course of Sovaldi for treatment of his hepatitis C virus (HCV). Findings:  Two physician reviewers found that Sovaldi is medically necessary and is for the treatment of the patients with HCV, genotype 3. In addition, treatment with Sovaldi is expected to be beneficial for this patient by potentially curing HCV infection and preventing damage of the liver and progression of the disease process and development of cirrhosis and its potential complications. The combination therapy with Sovaldi and ribavirin has been approved by U.S. Food and Drug Administration (FDA.) Therefore, Sovaldi is medically necessary for treatment of this patient with HCV genotype 3. Final Result: Two reviewers 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: Two reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology and are actively practicing. One reviewer is board certified in gastroenterology 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 male enrollee has requested for speech therapy for treatment of the enrollees moderate to severe delay in expressive and receptive language skills. Findings:  The physician reviewer found that Nelson and colleagues noted that, Speech and language development is considered by experts to be a useful indicator of a childs overall development and cognitive ability and is related to school success. The authors reported further that, preschool-aged children with speech and language delay may be at increased risk for learning disabilities once they reach school ageand have also shown more behavior problems and impaired psychosocial adjustment. According to a meta-analysis of 25 studies from Law and colleagues, approximately 6% of children have speech and language difficulties. Whilst most childrens difficulties resolve, children whose difficulties persist into primary school may have long-term problems concerning literacy, socialization, behaviour and school attainment. These reviewers concluded that overall there is a positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulties. Bernhardt and Major concluded that, results suggest that early phonological and metaphonological intervention can promote normalization of speech development and normal acquisition of literacy skills for at least some children with a history of severe phonological impairment. Finally, in a recent review of therapeutic intervention for children with speech and language delay, the following statement was made: there are good data available to support the effectiveness of speech-language therapy, particularly for children with primary expressive language disorder (McLaughlin, et al). Based on the literature, speech and language therapy is medically necessary and appropriate for this patient to address his speech and language challenges.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Botox (onabotulinumtoxin A). Findings: The records provided for review document that this patient presents with blepharospasm and hemifacial spasm. The patients provider has recommended treatment with Botox injections. A study noted that, Blepharospasm is a focal dystonia characterized by involuntary, repetitive eye closure. The American Academy of Neurology (AAN) guidelines on the treatment of blepharospasm state that Botox injections are supported by Level B evidence as probably safe and effective in the management of this blepharospasm. The AAN guideline noted that Botox is considered the first-line treatment of blepharospasm by most movement disorder specialists. Based on the current medical literature, the requested Botox injections are likely to be effective for symptomatic relief of the patients facial spasm and twitching. Therefore, the requested Botox (onabotulinumtoxinA) is medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested service 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 ophthalmology 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 23-year-old male enrollee requested partial hospitalization program (PHP) services for treatment of his behavioral health condition. Findings:  The physician reviewer found that the patient still required treatment for ongoing formulation of coping skills to prevent relapse, however he no longer required this intense of a level of contact with staff.  The patients treatment could have been continued at IOP level of care, with concurrent psychiatric medication management, individual counseling and outside 12-step meetings along with a sponsor. Therefore, based upon the documentation submitted for review, the services at issue were not and are not medically necessary for treatment of the patients medical condition.  Findings:  The physician reviewer found that
Appeal type: Experimental/Investigational
Decision: Overturned

The parent of an 11-year-old female enrollee has requested magnetic resonance imaging (MRI) of the pelvis and lumbar spine for evaluation of the enrollee's pain with positive HLA-B27 Disease Association test. Findings: Two physician reviewers found that the importance of Human Leukocyte Antigen B27 (HLA-B27) in this case is the association of this antigen and ankylosing spondylitis (AS). In general, the HLA-B27 test is not recommended for screening in an asymptomatic patients for AS and related diseases however in certain patients, the HLA-B27 test is of clinical value as an aid to further supporting or rejecting a diagnosis of AS. The HLA-B27 positive test result does not absolutely confirm the presence of AS but merely provides a statement of increased probability of the existence of AS in the symptomatic patient. The test is most useful to physicians who understand the use of probability reasoning in clinical decision making (Dougados). As in this case, the provider has ordered an MRI of the patients pelvis and lumbar spine to further establish a diagnosis. Thus, the requested MRI scans should be approved as the diagnostic quality is superior to other standard testing at this juncture in this patients evaluation.
Appeal type: Urgent Care
Decision: Overturned

A 75-year-old male enrollee has requested for emergency medical services and the placement of a pacemaker required on an emergent basis. Findings:  The physician reviewer found that The patient presented with symptomatic, third-degree heart block, or complete atrio-ventricular dissociation. This is considered a medical emergency as the clinical condition of a patient in complete heart block can deteriorate without warning. The standard of care is to emergently admit such patients to the hospital and apply trans-thoracic or temporary trans-venous pacing.
Appeal type: Medical Necessity
Decision: Overturned

A 20-year-old female has requested residential treatment level of care services for treatment of major depressive disorder.  Findings:  The physician reviewer found that modern psychiatric practice aims to place patients in the least restrictive treatment setting. When feasible, community intervention settings are thought to offer optimization of treatment gains. However, placement in more restrictive settings is often clinically appropriate. Applying the American Psychiatric Association (APA) practice guidelines, this patient has experienced a complicated and protracted negotiation of identity formation, which jeopardizes a healthy and successful individuation. This patients records indicate that her symptom complex undermines her progress as she has been unable to integrate the sustained learned behaviors or consolidate the treatment gains necessary to succeed in the community setting. Further, the patient has persistent affective symptoms and self-defeating behaviors. She has failed less restrictive treatment settings in this course of illness and her complex psychosocial stressors will likely undermine treatment in a lower level of care. All told, the patient requires the structure and 24-hour supervision provided by residential placement to cement the therapeutic skills necessary for success. In addition, premature discharge will burden the patient with risk for acute hospitalization.
Appeal type: Medical Necessity
Decision: Upheld

A 65-year-old female enrollee has requested Livalo (pitavastatin) 2mg per day for treatment of her hyperlipidemia.   Findings:  The physician reviewer found that review of the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested medication. All of the statin medications are competitive inhibitors of the same enzyme, HMG CoA reductase, including Lipitor (atorvastatin) and Livalo (pitavastatin), so it is reasonable that efficacy and side effect profiles among the different statin medications may be similar and predictable. For example, when switching between statin drugs, equipotent doses with regard to LDL-C reduction can be found to allow an easy transition to occur between two medications while maintaining similar efficacy. Specifically, 2mg of Livalo (pitavastatin) is equipotent compared to 10mg of Lipitor (atorvastatin). Large clinical trials have reported no significant difference in the incidence of persistently elevated aminotransferases between statin medications, with the exception of fluvastatin which may be less likely to be associated with liver enzyme elevation (Hippisley-Cox and Coupland). Moreover, observational data suggest that while discontinuation of statin therapy for side effects is relatively common, many patients tolerate the same statin or another statin when re-challenged (Zhang et al). With respect to Lipitor and Livalo, both have hepatic metabolism, similar efficacy and similar side effect profiles in spite of reported increased water solubility with Livalo. Since there is no contraindication, documented intolerance, proven inefficacy or a significantly dissimilar side effect profile of Lipitor compared to Livalo, the requested medication is not medically necessary at this time.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Xeljanz (tofacitinib) tablets.Findings: According to the most recent published Alopecia Areata Consensus of Experts (ACE) guidelines, Janus tyrosine kinase (JAK) inhibitors would be the ideal choice of systemic therapy in adults. Treatment of alopecia totalis/universalis includes systemic steroids, methotrexate, cyclosporine, JAK inhibition, and contact sensitization with diphenylcyclopropenone (DPCP) or squaric acid. Few treatment methods have been evaluated by randomized controlled trials to determine the most efficacious modalities to treat alopecia areata.  Therefore, it is challenging for clinicians to guide patients regarding the best therapeutic options. In a recent study, JAK inhibition has shown efficacy and safety. Therefore, Xeljanz (tofacitinib) tablets are medically necessary for the 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 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: Medical Necessity
Decision: Upheld

A 52-year-old female enrollee requested authorization and coverage of the prescription medication vioxx for the treatment of chronic lower back pain.  The Health Plan denied the enrollees request indicating that the requested treatment 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 medication is not medically necessary for treatment of the patients medical condition.