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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for intensity modulated radiation therapy (IMRT). Based on the review of the available data, that the proposed treatment of concurrent chemoradiation with IMRT to 60 Gy is within the current standard of care, and is likely to be beneficial than standard three-dimensional (3D) conformal radiotherapy. The typical histology for rectal carcinoma is adenocarcinoma, and not squamous cell carcinoma, as in the case of this patient. Treatment for squamous cell carcinoma tends to include a combination of the treatment regimens for squamous cell carcinoma of the anus and adenocarcinoma of the rectum. Thus, neoadjuvant chemoradiation using 60 Gy with Mitomycin C has been recommended, with surgery to follow. This is approach is supported by published literature. This aggressive approach involves treating to 60 Gy, yet the bowel has a tolerance of 50 Gy. Thus, the use of IMRT to spare exposure to the bowel is appropriate. Accordingly, the requested IMRT is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Findings:  Three physician reviewers found the requested IMRT is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested IMRT is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in radiation oncology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a six-year-old male enrollee has requested  speech therapy, occupational therapy and applied behavioral analysis (ABA) therapy for treatment of the enrollees medical condition. Findings:  The physician reviewer found that with regard to the requested ABA therapy, the medical literature strongly supports the treatment of autism with ABA therapy. The medical communitys customary and usual recommendation for an autistic child is ABA therapy. ABA therapy is well-documented as an effective therapy to significantly improve motor, verbal, and social interactive skills in autistic children. Myers and Johnson state, The effectiveness of ABA-based intervention in ASDs has been well documented through 5 decades of research by using single-subject methodology and in controlled studies of comprehensive early intensive behavioral intervention programs in university and community settings. Children who receive early intensive behavioral treatment have been shown to make substantial, sustained gains in IQ, language, academic performance, and adaptive behavior as well as some measures of social behavior, and their outcomes have been significantly better than those of children in control groups. The efficacy of ABA as the only effective behavioral treatment has been documented by many authors (Vismara and Rogers). Given the ample support for the use of ABA therapy in this setting, the request for treatment with ABA is medically appropriate and necessary for this patient.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested a continued stay at a skilled nursing facility for physical therapy for treatment of her medical condition.  Findings: The physician reviewer found that tibial plateau fractures are complicated injuries, each requiring an individualized initial approach whether surgical or nonsurgical (Yoon, et al). These fractures can result in significant functional impairments. The patient was still early in her rehabilitation course following a significant injury resulting in functional deficits. The patient was still making steady progress. Thus, continued stay at a skilled nursing facility for physical therapy was initially medically necessary. However, subsequently the patient was at the level of independent to supervision/set up for her self-care and household level mobility. As such, further care could have been provided in a less intensive setting. Continued inpatient care while awaiting delivery of durable medical equipment would constitute custodial level care; as such, continued stay at a skilled nursing facility for physical therapy was not medically necessary.  Final Result: The reviewer determined that a portion of the services at issue were medically necessary for treatment of the patients medical condition. Specifically, the patients continued stay at a skilled nursing facility for physical therapy was initially medically necessary.  Therefore, the Health Plans denial should be partially overturned.  Credentials/Qualifications: The reviewer is board certified in physical medicine and rehabilitation and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A sixty year-old-male who has a productive cough and shortness of breath with mild exercise is requesting authorization of a CT scan.  Reviewers Findings:The reviewing physician found that the value of a CT scan in the diagnostic evaluation of the chest is well established. This request for a CT scan by the pulmonologist is valid and the examination is medically indicated.  The reviewing physician found that the Health Plan denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for a laparoscopic anti-reflux procedure utilizing LINX.According to Saino and colleagues, the standard surgical intervention for GERD, Nissens fundoplication, cannot be performed in this case due to altered anatomy after sleeve gastrectomy. Saino and colleagues indicate that LINX is an effective, alternative procedure for GERD. Further, Hawasli and colleagues reports that LINX is safe and effective for the treatment of gastroesophageal reflux disease after sleeve gastrectomy. In this case, the patient has increased esophageal acid exposure and persistent symptoms of GERD. However, the patient has a history of a sleeve gastrectomy procedure, so a fundoplication cannot be performed. LINX has been shown to be a safe and effective alternative procedure in this clinical setting. Thus, a laparoscopic anti-reflux procedure utilizing LINX is medically necessary for the treatment of the patients medical condition.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 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 55-year-old female enrollee has requested for an MRI of the lumbar spine for evaluation of her lower back pain. Findings:  The physician reviewer found that if there are no radicular symptoms, conservative treatment with physical therapy and anti-inflammatories is appropriate and an MRI is not necessary.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Coflex Interlaminar Stabilization surgical procedure. Interspinous process decompression offers an intermediate step in the continuum of care for patients with neurogenic intermittent claudication associated with lumbar spinal stenosis. The Coflex device is made of a titanium alloy and designed to fit between two adjacent spinous processes in the lumbar spine. The FDA approved indications for Coflex is one- or two- level lumbar stenosis from L1 to L5 producing at least moderate impairment in skeletally mature patients who have failed six months of conservative treatment. The presence of back pain does not exclude a patient from undergoing treatment with Coflex. However, axial back pain alone without leg, buttock, or groin pain has not been demonstrated to provide the patient positive results. This patient has lumbar spinal stenosis with neurogenic claudication. The provider recommended decompression and implantation of a Coflex device. However, high quality studies have failed to demonstrate efficacy of this implant in improving mid- to long-term outcomes over decompression alone. Accordingly, the requested Coflex Interlaminar Stabilization surgical procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings:  Two of the three physician reviewers found the requested Coflex Interlaminar Stabilization surgical procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The 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: Physician reviewers 1, 2, and 3 are board certified in orthopedic surgery 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: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for orthopedic surgery consultation with a tertiary provider. Findings:  The physician reviewer found that This patients records document that he is being treated for Kienbocks disease on the right wrist. The patient presented to his provider with a right fifth finger injury and Kienbocks of the right wrist. Evaluation has included assessments by neurology and hand surgeon. The patient has requested a second opinion with another hand surgeon. Overall, the patients records do not support an indication for evaluation with a tertiary level of care orthopedic surgeon. There is a lack of detailed information regarding a right wrist physical examination by the patients primary care provider or that conservative management has been attempted. The evaluation and management of this patients complaints is within the expertise of the patients primary care provider. In addition, detailed documentation is not evident regarding significant pathology that would require a specialized provider at the tertiary level of care. The current evidence-based peer reviewed literature supports decision aids in the orthopedic management of patients, utilizing appropriate levels of care for initial evaluation and treatment. Anoushiravani and colleagues noted that as health care models shift from volume-based to value-based models, orthopedic surgeons must provide patients with highly reliable care, while consciously maintaining quality and providing timely interventions. Consistent with these recommendations, the patient does not meet the requirements for evaluation and treatment by an orthopedic surgeon at the tertiary level of care. Therefore, the requested orthopedic surgery consultation with a tertiary provider is not medically necessary for evaluation of this patient. Final Result: The reviewer determined that the requested services are not medically necessary for evaluation 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 ketamine hydrochloride 10 mg for treatment of his chronic low back pain. Findings:  The physician reviewer found that the documentation provided does not support the medical necessity for the requested medication compound in this clinical setting. In the documentation available for review, there is no documented failure of other standard treatments for neuropathic pain. Furthermore, the records do not show that all non-opioid medications classes have been optimized or tried.  According to the patient, Lyrica was helpful but it is unclear from the documentation if this was titrated to the highest therapeutic dose. Moreover, the providers own treatment plan was for pain psychology and physical therapy. However, these treatment options are not noted to be tried or completed. While there is some support in the medical literature that ketamine helps with neuropathic pain, there is also evidence that it is not effective.  Final Result: The reviewer determined that the requested medication compound is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in anesthesiology with sub-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

Findings:  The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Excimer laser treatment to the chin. Shin and colleagues note that for the treatment of vitiligo, combined treatment of narrow band (NB) ultraviolet light B (UVB) and excimer laser may enhance the treatment response without remarkable side effects. In a randomized, single-blind comparison study including 36 vitiligo lesions, Poolsuwan and colleagues reported that localized 308-nm excimer light appeared more effective and also more rapidly induced repigmentation than targeted 311-nm NBUVB for treatment of vitiligo. In this case, the patient has localized vitiligo and has failed treatment with topical steroids and tacrolimus. Given the potential psychosocial impact of untreated vitiligo, the requested service is medially indicated. Therefore, Excimer laser treatment to the chin is medically necessary for the 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 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

The parents of a 17-year-old female enrollee have requested authorization and coverage for residential treatment for treatment of the enrollees medical condition. The health plan has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees polysubstance abuse, self-mutilation, and depression.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the health plans denial on the basis that the requested services are not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested Orthovisc hyaluronan injections for treatment of her medical condition.   Findings: The physician reviewer found that the patient has bilateral degenerative osteoarthritis of the knees with secondary varus deformity. The rationale for the use of hyaluronan includes the concept that proinflammatory mediators and MMPs that stimulate chondrocytes to syntheses endogenous hyaluronic acid and proteoglycans will be affected positively by the injection of hyaluronic acid. However, the basic science rational for hyaluronan effecting arthritis of the knee has not been confirmed. Long-term tissue reaction to break down products of hyaluronan as well as acute reactions should also be considered along with the weak support provided by well-designed double blinded studies.  Therefore, due to the lack of clinical evidence supporting the use of hyaluronan injections for treatment of osteoarthritis of the knees, Orthovisc hyaluronan injections are not medically necessary for treatment of the patients medical condition.  Final Result: The reviewer determined that the injections at issue were 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 referral to a bariatric surgeon and gastric sleeve or gastric band surgery for treatment of the enrollees obesity. Findings:  The physician reviewer found that based on the documentation submitted for review, the request for referral to a bariatric surgeon and gastric sleeve or gastric band surgery are not medically necessary. The patient does not have documented morbid obesity or clinically severe obesity with a BMI of 40 or 35 with serious co-morbid conditions such as diabetes, hypertension or sleep apnea. In addition, the patient does not have BMI of 30-34.9 with type 2 diabetes on medication. The patient does not meet standard BMI metric criteria for consideration for bariatric surgery at this time. The medical necessity for referral to a bariatric surgeon or to undergo bariatric surgery is not supported for this patient. Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in 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 patient has requested authorization and coverage for Lyrica (pregabalin) 100 mg capsules. The patient presents with a history of neuritis and neuralgia, for which standard treatment options include gabapentin, Lyrica, and Cymbalta. The patient was unable to tolerate treatment with gabapentin due to side effects. The provider switched the patient from gabapentin to Lyrica and the patient had good benefit and no adverse effects. Given the limited medical therapies that are safe and effective for this patients neuritis and neuralgia, his positive response and ability to tolerate Lyrica support its continued use. All told, the requested Lyrica (pregabalin) 100 mg capsules are medically necessary for 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 anesthesiology with subspecialty certification in pain management 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: Urgent Care
Decision: Upheld

A 34-year-old male enrollee has requested emergency services for treatment of his medical condition.  Findings:  The physician reviewer found that the issue in this case is whether a prudent person in the patients circumstances would believe he or she was experiencing an emergency medical condition requiring emergency medical services. An emergency medical condition means a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in any of the following: placing the patients health in serious jeopardy, serious impairment to bodily function, or serious dysfunction of any bodily organ or part. With regard to this patient, he presented with a fever, body aches, and cold symptoms that had persisted for two days prior and had no chronic medical conditions. On physical evaluation, the patient was in no acute distress with a dry cough. His vital signs and pulse oximetry were within normal limits on arrival except for a temperature of 101.8 degrees. The patient did not have any concerning signs such as lethargy, vomiting, chest pain, seizure activity or decreased responsiveness. The patient had a common viral syndrome that is very common in this age group. The patient had been to urgent care only 24 hours earlier and received antibiotics and cough medicine. Although he indicates that he was instructed to go to the ER if his symptoms worsened, the evidence does not demonstrate that he experienced significant deterioration in his condition since being seen at the urgent care facility. Thus, to a layperson with an average knowledge of medicine, this patients signs and symptoms would not equate to an emergent condition. A prudent layperson would not believe these symptoms would place his health in serious danger, serious impairment to bodily functions, or cause serious bodily dysfunction without immediate treatment.