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

Nature of Statutory Criteria/Case Summary:   An enrollee has requested procedure code 64999 (unlisted nervous system procedure) and 64640 (neurolysis of peripheral nerve or branch) for treatment of his lumbar radiculopathy and sacroiliac joint arthritis. Three physician reviewers found that the services at issue were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. According to the documentation submitted for review, the physical examination does not show objective signs of sacroiliac pain including pain with facet loading or a positive Patricks test. In addition, there is a lack of documentation showing that the patient has failed conservative therapy, such as physical therapy. Based on the reasons provided above, the services at issue were not likely to be more beneficial Three reviewers determined that the services at issue were 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 anesthesiology with sub-specialty certification in pain medicine 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: The parent of an enrollee has requested authorization and coverage for 23 hours per week (100 hours per month) of direct applied behavioral analysis (ABA) therapy and 10.5 hours per month of supervision. Findings:  The physician reviewer found that there is sufficient evidence in the peer-reviewed literature supporting the correlation between treatment outcomes and ABA treatment intensity. In this case, the patient requires a high level of support to complete activities of daily living. She engages in high level non-compliance, which often presents safety concerns. She also demonstrates severe disruptive behaviors and high level stereotypy. The Health Plan has authorized 21.5 hours per week month (86 hours per month) of direct ABA therapy and nine hours per month of supervision, which is less than what has been provided in the past. Several studies have recommended 25 or more hours of weekly ABA to ensure optimal outcomes. Given the medical necessity of ABA therapy for children with autism, and the patients severe disruptive behaviors and high level of stereotypy, the request for 23 hours per week (100 hours per month) of direct ABA therapy and 10.5 has been established as medically necessary in this clinical setting. 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 pediatrics with sub-specialty certification in developmental-behavioral pediatrics 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

An enrollee has requested reimbursement for three-dimensional mammogram.  Findings:  The physician reviewer found that Breast tomosynthesis is a technique that was developed several years ago as a problem solving adjunct to routine mammography.  Applying the same basic concept as computed tomography (CT) scanning, the logic is that by separating the various layers of breast tissue, one can better detect abnormalities.  This has been shown to be most useful in the evaluation of dense breasts.  In this patients case, her breast density was described as heterogeneously dense.  While one could make the argument that her mammogram has not changed since the last study, it is specifically those patients who have dense breasts that can benefit most from tomosynthesis.  The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor.  Thus, three-dimensional mammogram performed was likely to have been more efficacious than other modalities for evaluating this patient. Final Result: The reviewers determined that the service at issue was 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: Physician reviewers are board certified in diagnostic radiology and 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: Medical Necessity
Decision: Upheld

A 64-year-old female enrollee has requested Nexium for treatment of her acute gastroenteritis. Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the requested medication. In this case, the patient has demonstrated cutaneous intolerance to omeprazole and pantoprazole. Severe cutaneous side effects of omeprazole and Nexium (esomeprazole) are rare but can identically include: erythema multiforme, toxic epidermal necrolysis, Stevens-Johnson syndrome, giant hives; while less severe cutaneous side effects include skin inflammation and sun sensitivity. Cross reaction can thus be anticipated and safety concerns for the patient exist given the comparative biochemical similarity of omeprazole and esomeprazole. Furthermore, the increased effectiveness of esomeprazole (Nexium) is outweighed by its risk of significant cutaneous manifestations similar to omeprazole. Thus, given the safety concerns posed, the medical necessity for substituting Nexium for omeprazole is not demonstrated in this clinical setting. Therefore, the medical necessity of the requested medication has not been established in this patients case.
Appeal type: Medical Necessity
Decision: Overturned

A 59-year-old male enrollee requested authorization and coverage of aspirin desensitization. The Health Plan denied the request indicating that the requested services are not medically necessary for treatment of the enrollees asthma.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: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested Supartz injections for treatment of his osteoarthritis.   The physician reviewer found that carefully conducted double-blinded studies published in the medical literature do not demonstrate any clinical effect from hyaluronan injections. In addition, there is a recognized incidence of aseptic inflammatory reactions due to allergic response and risk of iatrogenic infection within the joint. A recent meta-analysis of the efficacy of viscosupplementation concluded after review of a total of 89 trials involving 12,667 patients with knee osteoarthritis that viscosupplementation is associated with a small and clinically irrelevant benefit and that there is an increased risk of serious adverse effects. Several studies evaluating repeated treatment protocols have reported adverse events including inflammatory changes within the knee joint. Further, the risk of sensitization is expected to increase after repeated exposure to an antigenic substance. All told, the requested Supartz injections are not supported as medically necessary for treatment of this patients degenerative joint disease.  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 orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Victoza for treatment of the enrollees diabetes, type II. Findings:  The physician reviewer found that according to the American Diabetes Association as to pharmacologic approaches to glycemic treatment, A patient-centered approach should be used to guide the choice of pharmacologic agents. Considerations include efficacy, hypoglycemia risk, impact on weight, potential side effects, cost, and patient preferences.  Per the guidelines for glycemic targets, this patients diabetes control is not at goal of hemoglobin A1c 6.5-7%. The patient has tried Victoza and has experienced that this medication is the best treatment option for him. Victoza is a GLP-1 receptor analog, and has a mode of action that is more direct in mimicking the hormone GLP-1, which is deficient in diabetes. Additionally, Victoza has been shown to be more potent than Januvia, a DPP-4 inhibitor. However, while the medical literature supports the efficacy of Victoza for treatment of type II diabetes, Victoza is not to be used with Januvia. Januvia, like Victoza, is also an incretin based therapy. A clinical note documents that Januvia 100 mg tablet is one of the patients active medications. As such, the use of both medications is redundant and the medical studies do not support the use of these medications together. Therefore, while Victoza has been shown to be an effective treatment and appears to work better for this patient, Victoza is not medically indicated when Januvia is also being used. For these reasons, Victoza is not medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in 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: Experimental/Investigational
Decision: Upheld

A 53-year-old female enrollee has requested a PET/CT scan for evaluation of her fibrosarcoma.  Findings:  Two physician reviewers found that the use of PET/CT scans for evaluation of patients with soft tissue sarcoma is limited to the initial staging, monitoring response to treatment and for determining prognosis of the patients tumor.  There is a lack of support in the peer-reviewed literature for the use of PET/CT scans for surveillance purposes in asymptomatic patients with prior history of soft tissue sarcoma.  Ilaslan and colleagues noted that after definitive treatment, MRI remains the most sensitive imaging tool for diagnosing local recurrences of either bone or soft tissue sarcomas.  For patients who have been treated for sarcoma, PET/CT studies are useful if there is clinical evidence of recurrence or metastatic disease or if findings on conventional imaging are equivocal.  This patient has no clinical evidence of recurrence or suspected metastatic disease.  All told, the requested PET/CT scan is not likely to be the most beneficial method for evaluating this patient.
Appeal type: Medical Necessity
Decision: Upheld

A 52-year-old female enrollee has requested a panniculectomy and abdominoplasty for the treatment of her excess skin. Findings:  The physician reviewer found that an abdominoplasty is a cosmetic procedure that involves placement of transverse suprapubic/lower abdominal and periumbilical incisions. The abdominal skin is then tightened by excising the caudal portion of abdominal skin and creating a new umbilical opening higher up on the skin that has now been stretched downward. In most cases, tightening of the abdominal musculature is also performed by suture plication of the rectus sheaths. This maneuver repairs a diastasis recti, which is a widening of the linea alba with separation of the rectus muscles.  It is not a medically necessary procedure. Panniculectomy is a lesser procedure that only involves removal of the lower abdominal skin without the muscle tightening or the supraumbilical skin tightening via periumbilical and lower abdominal incisions. It would be medically necessary rather than cosmetic in nature if the removed skin has a history of recurrent infections or is necrotic. The pannus would have to be quite large to cause lower back pain. The mere presence of a pannus and/or its psychological or physical burden on the patient does not automatically make its removal medically necessary. There is no evidence in the reviewed materials that would support the medical necessity of a panniculectomy.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for right and left foot orthotics (CPT L3020). Findings:  The physician reviewer found that orthotics, either custom or prefabricated, are appropriate for the treatment of patients with plantar fasciitis. However, prior to initiation of a new pair of orthotics, it is reasonable for the patients provider to perform an extensive physical examination describing the patients foot structure. The provider should document specific clinical biomechanical abnormalities to support an indication for custom orthotics. This patient presents with a history of foot pain, plantar fasciitis, hallux valgus, and pronation of feet. The provider reports that the patients current foot orthotics are 2.5 years old and no longer support the patients abnormal pronation. The patients records do not include an assessment of the patients current orthotics or description of the orthotic breakdown. Moreover, there is a lack of documentation of a physical examination of the patients feet in the records provided for review. All told, the requested right and left foot orthotics (CPT L3020) are not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested equipment is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is licensed D.P.M., board certified in podiatry 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

Nature of Statutory Criteria/Case Summary:   An enrollee has requested a water circulating cold pad with pump for treatment of her medical condition.  Findings:  Three physician reviewers found that the submitted documentation fails to demonstrate the superior efficacy of the equipment at issue.  Researchers concluded that the potential benefits of cryotherapy on blood loss, postoperative pain, and range of motion may be too small to justify its use, and the quality of the evidence was very low or low for all main outcomes.  The authors noted that well-designed randomized trials were needed.  Based upon a review of the recent literature, the routine use of continuous flow cryotherapy after a total knee arthroplasty is not indicated.  The equipment at issue was not and is not likely to be more beneficial for treatment of the patients medical condition than standard cold packs.  Final Result: Three reviewers determined that the equipment at issue was not and 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 orthopedic surgery 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

A 62-year-old male enrollee has requested pulsed neurofrequency neurolysis for treatment of his back pain.  Findings:  Three physician reviewers found that Geurts and colleagues reported on 1001 patients in the only published randomized, double-blind, controlled trial of radiofrequency lesioning of the dorsal root ganglia for the treatment of lumbosacral radicular pain. The authors concluded that, lumbosacral radiofrequency lesioning of dorsal root ganglia failed to show advantage over control treatment with local anaesthetics. Thus, its use as routine treatment in lumbosacral radicular pain should not be advocated. Given the poor outcome in the only randomized, double-blind, controlled trial published to date, and the lack of studies on pulsed RF lesioning, thus the procedure has not been proven effective and should be considered investigational at this time.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: A 31-year-old female enrollee has requested reimbursement for inpatient hospitalization services provided on 10/16/18 for treatment of the enrollees major depressive disorder and personality disorder. Findings:  The physician reviewer found that At issue in this case is whether the inpatient psychiatric hospitalization services at issue, provided on 10/16/18, were medically necessary for treatment of the patients behavioral health condition.The American Psychiatric Association Guideline for major depressive disorder notes the determination of an appropriate setting for treatment should include consideration of the patients symptom severity, co-occurring psychiatric or general medical conditions, available support system, and level of functioning  determination of a treatment setting should also include consideration of the patients ability to adequately care for him- or herself, to provide reliable feedback to the psychiatrist, and to cooperate with treatment of the major depressive disorder  measures such as hospitalization should be considered for patients who pose a serious threat of harm to themselves or others.Suicidal ideation is not a binary concept but a spectrum of thoughts. One is not 100 percent suicidal one day and then zero percent suicidal the next. If a patient is ill enough to be admitted for suicidal ideation, it is prudent to observe for at least one or two more days after their final documented report thereof. Given the severity of the patients illness with admission for suicidal ideation, the additional day of inpatient treatment was in accordance with generally accepted standards of medical practice, and clinically appropriate for the patient's illness, and is therefore medically necessary.Final Result: The reviewer determined that the services at issue were medically necessary for treatment of the patients behavioral health condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in 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.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a five-year-old female enrollee has requested  occupational therapy for treatment of her autism spectrum disorder and attention deficit hyperactivity disorder. Findings:  The physician reviewer found that the effectiveness of occupational therapy (OT) in the treatment of autistic children is well-documented. Pfeiffer, et al. reported on an extensive meta-analysis of the literature and concluded that OT is effective in reducing many of the problematic mannerisms associated with autism. May-Benson and Koomar also performed a meta-analysis of 27 journal articles utilizing sensory integration techniques for autistic children and concluded that sensory integration was effective.  Therefore, it is medically necessary that this patient receive the requested individual occupational therapy.
Appeal type: Experimental/Investigational
Decision: Overturned

A 50-year-old female enrollee has requested Botox injections for the treatment of her hemiparetic migraine. Findings:  Two physician reviewers found that the use of botulinum toxin (Botox) for management of headaches remains an off-label indication. However, recent publications suggest that Botox is an effective treatment for chronic migraine without medication overuse and is helpful in managing refractory headache syndromes. In fact, this patient has been receiving Botox for many years with significant prophylactic effect which has resulted in a significant decrease in the number and intensity of her headaches as well as reduction in the episodes of hemiparesis. Given the excellent results the patient has achieved from Botox, and the suboptimal results she experienced with other prophylactic agents, Botox represents a superior treatment option in this particular case.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested Aubagio for treatment of his multiple sclerosis. The physician reviewer found that the submitted documentation establishes the medical necessity of the requested medication. This patient presents with multiple sclerosis and has tried two injectable drugs with reported side effects. He has been stable with treatment of Aubagio for two years.  Aubagio is U.S. Food and Drug Administration approved for relapsing forms of multiple sclerosis. There is medical literature supporting Aubagio as effective at reducing relapses, MRI activity and slowing disability progression. In this case, treatment with Aubagio appears to be effective for this patient. Based on the medical literature and clinical documentation provided, the request for treatment with Aubagio is medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the requested medication is medically necessary for evaluation 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.