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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Prevpac combo pack. The submitted documentation fails to demonstrate the medical necessity of the requested medication. In this case, there is a lack of support for the use of the Prevpac brand formulation rather than the formulary alternatives, which are the generic form of the same medications (lansoprazole, clarithromycin, amoxicillin). The generic alternatives have proven effective when taken as separate tablets and capsules, and are supported by American College of Gastroenterology guidelines for the treatment of Helicobacter pylori infection. For these reasons, Prevpac combo pack is not medically necessary 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 internal medicine with sub-specialty certification 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: Medical Necessity
Decision: Upheld

A 50-year-old male enrollee has requested neurofeedback (cognitive rehabilitation therapy) for the treatment of his mild traumatic brain injury. Findings:  The physician reviewer found that neurofeedback is not included in the current practice guidelines for mild traumatic brain injury. A study by Ponsford found that there is a need for a more uniform standard of assessment and management. The lack of research makes the treatment for mild traumatic brain injury highly variable. The supporting rehabilitation data is not robust. A National Institutes of Health consensus development panel on rehabilitation showed limited data on the effectiveness of cognitive rehabilitation programs because of the heterogeneity of subjects and intervention outcome studies. As such, the additional information provided does not establish the medical necessity of neurofeedback in this setting.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for a left thumb prothesis.Findings:  Two physician reviewers found that there is sufficient support for the requested device in this patients case. The records document that the patient is post-amputation. The thumb affects 40% of hand function, and any type of device should afford length, stability, and opposition. The thumb contributes to grasping function. This patients condition creates significant impairment in completion of activities of daily living. Given this patients shortened thumb, lengthening with a prosthesis is medically appropriate. In this clinical setting, the requested device is likely to assist in future functional recovery. In sum, the requested left thumb prothesis is likely to be of greater benefit than other treatment options. Final Result: The reviewers determined that the requested device 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: Physician reviewers 1, 2 and 3 are board certified in plastic surgery with sub-specialty certification in surgery of the hand 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

Nature of Statutory Criteria/Case Summary:  An enrollee has requested bronchial thermoplasty for treatment of his severe persistent asthma.  Two physician reviewers found that in this patients case, the requested services are likely to be more effective than other available treatment options. Based on the medical records submitted for review, the patient meets the criteria for severe persistent asthma. Bronchial thermoplasty is an accepted modality for reduction in exacerbations of severe persistent asthma. It has been shown to reduce hospitalizations, reduce emergency room (ER) visits and reduce exacerbations. Bronchial thermoplasty treatments also improve a patients quality of life and this patient would benefit from this procedure. Therefore, for the reasons provided above, the request for bronchial thermoplasty is likely to be more beneficial than other treatment alternatives in this patients case.  Final Result: Two reviewers determined that the requested services are 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 internal medicine and pulmonary disease and is actively practicing. Two reviewers are board certified in internal medicine with sub-specialty certification in pulmonary disease 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: Upheld

ature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for ultrasound guided perirectal trigger point injections (CPT 99214, 20552, 20553, and 76942). Findings:  The physician reviewer found that treatment options for rectal pain syndromes and concluded that appropriate treatments included electrogalvanic stimulation, biofeedback training, muscle relaxants, digital massage of the levator ani muscles, and sitz baths. In one study, patients with chronic proctalgia received either electrical stimulation or digital massage of the levator ani and warm sitz baths or pelvic floor biofeedback plus psychological counseling. The analysis showed that 87% reported adequate relief of rectal pain after biofeedback. This improvement was maintained 12 months later.Hong and Ding reviewed current treatments for female pelvic floor dysfunction with regards to myofascial pelvic pain. Their review suggested that myofascial pelvic pain (MFPP) can be effectively treated with a variety of physical therapy techniques, such as manual therapy, biofeedback, relaxation training, electrical stimulation, and medication. Suppository medication with a muscle relaxant, nonsteroid anti-inflammatory drugs, and painkillers for 1 to 2 weeks were helpful for most patients in initial management. Subsequently, physical therapy carried by a well-trained physical therapist was also critical. However, no standardized or superior physical therapy protocol was reported. For refractory MFPP, intra-levator muscle Botox injections with a standard pudendal block kit can be considered.In this case, the patient reported unspecified rectal pain for 2 to 3 years. Provider notes do not indicate that a pelvic or rectal exam were performed. These notes also do not include diagnoses of myofascial pelvic floor pain or a recognized functional anorectal pain syndrome such as proctalgia fugax or levator ani syndrome. As noted above, the review by Rao discussed several treatment options for functional rectal pain syndromes, however, trigger point injections were not discussed or recommended. A more recent review by Hong from 2019 discussed treatment options for pelvic floor pain, and likewise, there was no discussion or recommendation for myofascial trigger point injections. Accordingly, the ultrasound guided perirectal trigger point injections (CPT 99214, 20552, 20553, and 76942) at issue were not medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the services at issue were not medically necessary to treat the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in anesthesiology, with subspecialty 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: Medical Necessity
Decision: Overturned

The patient has requested reimbursement and prospective authorization and coverage for residential treatment center (RTC) services. Per the American Society of Addiction Medicine (ASAM) criteria, this patient meets Level 3.1 criteria for RTC services. ASAM criteria focuses on six dimensions to determine the appropriate level of care, which includes: (1) intoxication and withdrawal potential; (2) biomedical conditions; (3) emotional, behavioral and cognitive conditions; (4) readiness to change; (5) relapse, continued use, or continued problem potential; and (6) recovery environment. Given the findings, the patient meets the six ASAM dimensions to support treatment in a Level 3.1 RTC. Therefore, the RTC services were and are medically necessary for treatment of this patient.Final Result: The reviewer determined that the services at issue were and 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 psychiatry with subspecialty certification in addiction 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

The patient is a 28-year-old female with a history of large, bulging varicosities of the labia that became very painful with prior pregnancies and labial pain during her menstrual cycle. However, the patient is currently asymptomatic and does not have any large, bulging labial varicosities, only telangiectasia and 2mm to 3mm surface reticular veins in the groin region. The patients provider has submitted a request for authorization of sclerotherapy to the telangiectasias and reticular veins to prevent possible problems with future pregnancies and to prevent labial pain during the patients menstrual cycles. The Health Plan denied the request based upon a determination that the therapy is not medically necessary.The patient has only superficial telangiectasias and reticular veins at the present time.  Sclerotherapy is appropriate for labial varicosities when the symptomatic vein can be visualized and directly injected, which is not the case in this instance. There is no evidence in the literature that injection of these small, asymptomatic vessels will effectively treat labial pain or prevent complications with future pregnancies. Therefore, I have determined the requested therapy is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a 15-year-old female has requested residential psychiatric treatment for the treatment of the enrollees mood disorder and oppositional defiant disorder. Findings:  The physician reviewer found that at the time of admission, the patient was stable. She was not suicidal, homicidal or psychotic. She did not require 24/7 observation and monitoring. She had no medical issues and no side effects to treatment. She was cooperative and able to care for herself. While she had a number of aberrant behaviors in the past, she is said to have improved while in the wilderness program. A lesser level of care could have safely and effectively met this patients clinical needs. Treatment in a residential facility was not and is not medically indicated for this patient.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a four-year-old male enrollee requested authorization and coverage of occupational therapy equipment for the treatment of autism.  The Health Plan denied the enrollees request indicating that the requested equipment is not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer overturned the health plans denial on the basis that the requested equipment is medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld

A 60-year-old female enrollee has requested for an annual PET scan for evaluation of the enrollee, who has a history of malignant fibrohistiocytoma, breast cancer and lung cancer. Findings:  Two physician reviewers found that there is no indication that this patient has received any treatment recently, or has any evidence of either elevation of tumor markers or clinical evidence of recurrent disease. PET scanning has an impact on patients who have suspected recurrence.  The role of PET scanning in terms of routine surveillance has not been supported in the literature.  In this patients case, there is no suggestion that a change in her treatment is anticipated depending on the results of the PET scan.  The submitted records do not indicate suspicion for recurrence to warrant a PET scan at this time.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 52-year-old man who has painful onychomycosis of the toenails. His dermatologist recommended oral Lamisil, after a failed treatment of Lamisil cream. Because he was concerned about side effects he declined oral medication and requested Penlac solution. The Health Plan has denied coverage for the requested medication on the basis it is not medically necessary.Medically appropriate treatments for fungus nail infections include oral antifungals, fungoid solution, and Penlac solution. The submitted records indicate the patient wishes to avoid the side effects associated with oral Lamisil. Though Penlac solution is not as effective in the treatment of onychomycosis as Lamisil tablets, it has shown some success and the risk of systemic side effects is less than minimal. As such, Penlac solution is medically appropriate for treatment of the patients condition and should be authorized. Accordingly, I have determined that the requested medication is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested proton beam radiation therapy for the treatment of his medical condition. Findings:  Three physician reviewers found that the current medical evidence has not demonstrated the superior efficacy of the requested services. Proton beam radiation therapy has not been proven to be more beneficial than photon-based intensity modulated radiation therapy in this clinical setting.  There is a lack of published trials with clinical endpoints comparing proton beam therapy and photon-based intensity modulated radiation therapy for oropharyngeal carcinomas.  Clinical studies comparing proton beam radiation therapy and photon-based intensity modulated radiation for paranasal carcinomas and skull base tumors are not clinically translatable to oropharyngeal carcinomas, as treatment volumes are usually different.  All told, proton beam radiation therapy is not likely to be superior over other treatment options.Final Result: Three reviewers determined that the requested services are 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: Reviewers 1, 2, and 3 are board certified in radiation oncology 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: Upheld

The parent of a 13-year-old male enrollee has requested growth hormone therapy (Nutropin AQ) for treatment of the enrollees short stature.  Findings:  The physician reviewer found that according to Lawson Wilkins Pediatric Endocrine Society guidelines, a trial of growth hormone therapy should be approved for children with otherwise unexplained short stature who pass growth hormone stimulation tests but who meet most of the following criteria: (1) height more than 2.25 standard deviations below the mean for age or more than 2 standard deviations below the mid-parental height percentile; (2) growth velocity less than the 25th percentile for bone age; (3) bone age more than 2 standard deviations below the mean for age; (4) low serum IGF-1 and/or IGFBP-3; and/or (5) other clinical features suggestive of growth hormone deficiency.  This patient does not meet all of the above criteria.  All told, the requested growth hormone therapy (Nutropin AQ) is not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

A 51-year-old male enrollee has requested magnetic resonance imaging (MRI) for evaluation of his shoulder and back pain.  Findings:  The physician reviewer found that this patients records do not include any red flags to indicate immediate advanced imaging with MRI is medically necessary for further evaluation of his shoulder pain. MRI may be indicated for evaluation of chronic shoulder pain the custom following an adequate trial of conservative management including physical therapy as no clinical emergent findings are present. A trial of physical therapy has been prescribed for this patient but there is no record in the chart that such a referral has been made or that there has been an attempt at such conservative management. Therefore, the patient should be treated with conservative management including a trial of physical therapy prior to consideration for further work-up with MRI. All told, the requested diagnostic procedure is not medically necessary for evaluation of the patients left shoulder pain.
Appeal type: Medical Necessity
Decision: Overturned

The patient has complete spinal cord injury and tertraplegia due to hyperextension of his neck after a fall. He received two courses of inpatient acute rehabilitation therapy in a skilled nursing facility (SNF). He progressed well in the second acute hospital-based rehabilitation, probably because he had made some neurologic recovery. He was discharged to another SNF on 2/6/04. A request has been made for continued inpatient rehabilitation services. The Health Plan has denied the request on the basis that the requested services are not medically necessary.Review of the information provided demonstrates that the patient no longer required acute inpatient rehabilitation therapy as of 2/6/04. However, it appears the patients course of rehabilitation ended abruptly upon transfer to another SNF. Though the patient was near the end of his rehabilitation program he had not completed the program. Based on the submitted evidence, as of 2/6/04 the patient required daily skilled inpatient rehabilitation therapy for a period of four weeks. Furthermore, outpatient therapy was not indicated at that time as there was no appropriate discharge planning in place for the patient.Therefore, I have determined that daily skilled inpatient rehabilitation therapy was medically necessary after 2/6/04. As such, the Health Plans denial should be partially overturned. Given the length of time since the cessation of inpatient rehabilitation therapy, the patient should undergo an evaluation at his current SNF to determine his capabilities with the environment and to ascertain whether he is at maximum potential. If the examining provider determines that additional inpatient rehabilitation therapy is medically indicated, the patient should receive four weeks of daily skilled inpatient rehabilitation therapy. However, at that time, the patient should be reevaluated by his physician to determine if further skilled inpatient rehabilitation therapy is needed.
Appeal type: Medical Necessity
Decision: Overturned

A 60-year-old female enrollee has requested authorization and coverage for Provigil 100 mg for treatment her multiple sclerosis.  Findings:  The physician reviewer found that Provigil is used in clinical practice by neurologists in the treatment of patients with fatigue associated with multiple sclerosis. This is an off-label use of the medication, it is effective in reducing fatigue associated with multiple sclerosis.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for bilateral custom foot orthotics. This patient is noted to have a history of painful plantar fasciitis, which was treated with plantar fasciotomy and eventually returned. She has been advised to stretch her plantar fascia daily, wear supportive shoes, and be fitted with custom foot orthotics. Custom foot orthotics have been utilized successfully for the treatment of plantar fasciitis and are within the current standard of care in this clinical setting. Researchers reported that 85-90% of patients with plantar fasciitis can be managed without surgery. The authors noted that, A wide variety of orthosis options are available for the management of plantar fasciitis. The use of shoe inserts (e.g., silicone heel pads, felt pads, and rubber heel cups) in combination with stretching exercises has been shown to provide superior short-term improvement in heel pain compared with stretching alone. Based on the documentation provided, this patient has continued arch pain even after plantar fasciotomy and she continues to perform stretching of the plantar fascia. There is evidence that addition of orthosis in the shoe can provide additional benefit. For these reasons, requested bilateral custom foot orthotics are medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested equipment is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is a 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: Medical Necessity
Decision: Upheld

The parent of a nine-year-old male enrollee has requested sound sensitivity treatment and other services included in the treatment plan offered by Developmental Spectrums (e.g. laboratory testing, dietary supplements and medications) for the treatment of the enrollees autism and central auditory processing disorder. Findings:  The physician reviewer found that there is no evidentiary basis for the application of sensory integration therapy, auditory integration therapy or sound sensitivity treatment in the treatment of autism according to a current review of autism published in the peer-reviewed literature. With regard to the other treatment modalities offered by the Autism Spectrums clinic, these interventions are not evidence-based and are far less likely to have a positive impact on the patients behavior and level of functioning than the more standard approach outlined following the patients multidisciplinary evaluation.