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

The parent of a 4-year-old male enrollee has requested applied behavioral analysis (ABA) therapy at a frequency of 40 hours per weekfor treatment of the enrollees autism.  Findings:  The physician reviewer found that applied behavioral analysis has been shown to be beneficial in the treatment of behaviors associated with autism spectrum disorder (Dawson et al). Treatments based on operant principles of learning are more effective for reducing maladaptive behaviors than alternative treatments. A 5-year randomized-controlled study involving 48 children with autism found significant improvements in IQ, adaptive behaviors and overall autism diagnosis using an Early Start Denver Model interaction based on developmental and applied behavior analysis principles and with at least 25 hours of intervention services weekly (Dawson et al). Warren and colleagues reviewed 34 studies of early intervention in autism. The authors concluded that studies of Lovaas-based approaches and early intensive behavioral intervention variants and the Early Start Denver Model resulted in some improvement in cognitive performance, language skills, and adaptive behavior skills (Warren et al). A recent retrospective study by Kelley and colleagues compared a group of school-aged children who had been diagnosed with an autism spectrum disorder (ASD) when they were toddlers and who currently have optimal outcome to typically developing peers and peers with high-functioning ASD. Sixty-two percent of children in the optimal outcome group received intensive behavioral therapy greater than 20 hours/week) whereas only 13% of the high-functioning group received this level of intervention (Kelley et al).  Treatment intensity may play an important role and ABA therapy must be implemented at a sufficient intensity in order to provide optimal outcomes (Granpeesheh et al). Granpeesheh and colleagues studied 379 children with autism who were receiving behavioral intervention services and found that increases in treatment intensity led to continued increases in treatment gains. The authors noted the rate of learning was much higher for those children receiving relatively high intensity treatment of at least 40 hours/week. Therefore, this patient will continue to require ABA therapy as recommended and it is medically necessary that this patient receive 40 hours per week of ABA therapy.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Subsys (fentanyl sublingual spray) for treatment of his chronic pain.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication.  This patient has non-malignant chronic pain, which will often worsen or recur as a result of opioid rebound.  The current standard of care for chronic pain is treatment in a multidisciplinary practice to include physical therapy, massage therapy, cognitive behavioral therapy, and injections to help reduce pain.  The medical literature reported that high-dose opiates might contribute to pain sensitization via opioid-induced hyperalgesia, decreasing patient pain threshold and potentially masking resolution of a preexisting pain condition.  In this retrospective study, the majority of patients undergoing detoxification of high-dose opiates for chronic pain reported a significant decrease in pain at the end of the study, further supporting the theory of opioid-induced hyperalgesia.  The medical literature reported that prolonged use of high-dose opiates might induce tolerance, abnormal pain sensitivity, and hormonal effects. The aim of current guidelines is to protect patients from the adverse effects of opioid therapy.  All told, the requested Subsys (fentanyl sublingual spray) is not medically indicated 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 anesthesiology with sub-specialty 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested breast tomosynthesis for evaluation of her medical condition.  Findings: Three physician reviewers found that 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.  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,  breast tomosynthesis was likely to have been of greater benefit than other methods of evaluating this patient.  Based upon the information set forth above, the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: Three reviewers determined that the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: All three physician reviewers are board certified in internal medicine with sub-specialty certification in diagnostic radiology and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The enrollee is requesting authorization and coverage for custom foot orthotics. The enrollee has plantar fascial fibromatosis. She also has left heel pain that has been unresponsive to anti-inflammatories, pain medications, shoe modification, over-the-counter orthotics, stretching, and ice. She reported her pain as throbbing and reported she was unable to walk. Her podiatrist recommended physical therapy and custom orthotics. This enrollees records show a three-month history of heel pain, and records support the enrollee experienced a similar issue in the past, which responded only to an injection. Medical records do not show the enrollee was offered a steroid injection. Although prescribed, the records do not support the enrollee completed a course of physical therapy. There is no evidence of a follow up with the provider to assess the enrollees response to the treatment plan. There is insufficient evidence to support the enrollee has performed and failed conservative measures. Literature indicates customized and prefabricated foot orthoses demonstrates a similar effect on pain relief, and were similar in their effect on function in the medium term. There is moderate-quality evidence that foot orthoses are effective at reducing pain in the medium term; however, it is uncertain whether this is a clinically important change. Research indicates there are no data on the efficacy of these devices as compared with placebo or no treatment.Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in podiatric 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 similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested breast tomosynthesis for evaluation of her medical condition.  Findings:  Three physician reviewers found that 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.   It is specifically those patients who have dense breasts that can benefit most from breast tomosynthesis.  The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor.  Thus, breast tomosynthesis was likely to have been more efficacious than other methods of evaluating this patient.   Final Result: Three reviewers determined that the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: All three reviewers are board certified in diagnostic radiology and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested group speech therapy for social skills for treatment of the enrollees pervasive developmental disorder. Findings:  The physician reviewer found that review of the submitted documentation and medical literature demonstrates the medical necessity of the requested services. Social skills groups are effective for teaching social skills and pragmatic language skills to children with autism. In this case, the speech therapy evaluations indicated that the patients pragmatic language skills are not behind enough to require speech therapy. However, the patients overall autism symptoms indicate that she does need intervention. For the reasons stated, group speech therapy for social skills is 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 and 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

A 70-year-old female enrollee has requested Botox injections for the treatment of her refractory post-herpetic trigeminal neuralgia. Findings:  Three physician reviewers found that this patient has post-herpetic neuralgia in the trigeminal nerve distribution, and does not have idiopathic trigeminal neuralgia. There are no surgical procedures that have been found to be effective in PHN. This patient has tried and failed at least four standard treatments. The only FDA approved therapy she has not tried is Cymbalta. The patient and her neurologist report a remarkable improvement in her facial pain from Botox injections. Botox has been utilized for a variety of chronic pain syndromes including occipital neuralgia, trigeminal neuralgia and post-herpetic neuralgia. There are case reports of Botox being beneficial in patients with intractable post-herpetic neuralgia. Botoxs mechanism of action suggests its potential to be effective in treating a variety of chronic focal neuropathic disorders. Given the patients failure on multiple standard therapies, the lack of effective alternative standard therapies, and her prior long-standing high response to intermittent Botox therapy, I find that Botox was and is likely to be superior to any standard therapies available in this setting.
Appeal type: Medical Necessity
Decision: Overturned

A 59-year-old female enrollee has requested Lyrica for treatment of her trigeminal neuralgia. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested medication.  Trigeminal neuralgia is a painful nerve syndrome of the face.  Treatment of trigeminal neuralgia includes surgical decompression as well as medication management.  Pregabalin (Lyrica) is a gamma-aminobutyric acid (GABA) analogue with structural similarity and actions similar to gabapentin.  Like gabapentin, Lyrica has antiepileptic, analgesic and anxiolytic activity.  There is sufficient support for the requested medication in this clinical setting.  Perez and colleagues reported on the effects of Lyrica in 65 patients with trigeminal neuralgia refractory to analgesic therapy.  Per the authors, 59.4% of these patients experienced pain reduction of 50% or more.  In this case, the patient has tried a number of interventions, including surgery and medications.  The records document continued pain and burning of the face.  There is a lack of treatment options in this patients case.  All told, Lyrica is medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

A 39-year-old female enrollee requested authorization and coverage of gastric bypass surgery. The Health Plan denied the request indicating that the requested procedure is not medically necessary for the treatment of the enrollees morbid obesity.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plans denial on the basis that the requested procedure is medically necessary depending upon the results of a psychological evaluation.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for pelvis magnetic resonance imaging for evaluation of the enrollee's rising prostate specific antigen (PSA) level. Findings:  Three physician reviewers found that while there are emerging studies to support magnetic resonance imaging (MRI) in the management of prostate cancer, there is still a relative paucity of reliable data. Further studies are recommended. This patient has not had an initial biopsy. At this time, standard transrectal ultrasound and guided biopsy of prostate remains to be the initial diagnostic modality.  In sum, pelvis MRI is not likely to be more beneficial than the other standard methods for the evaluation of this patients medical condition. Final Result: The reviewers determined that the requested services are not likely to be more beneficial for evaluation 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 urology and are actively practicing. The reviewer are 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 Xeomin (incobotulinumtoxinA) injections for treatment of her abdominal muscle spasms. Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the requested therapy. There is a lack of published scientific evidence to support the efficacy of Xeomin in this clinical setting. The medical records note that the patient complains of abdominal muscle spasms and an MRI revealed she is found to have thoracic nerve root cysts. Per the manufacturers prescribing information, Xeomin is approved for the treatment of cervical dystonia, blepharospasms and wrinkles. Xeomin is not FDA approved or indicated for the treatment of abdominal muscle spasms secondary to neural foramen compression. Furthermore, there is a lack of peer-reviewed medical literature that supports the use of Xeomin for abdominal muscle spasms. Given the lack of scientific data demonstrating the efficacy of Xeomin for the requested indication, the medical necessity of the requested therapy has not been established.
Appeal type: Urgent Care
Decision: Overturned

The parent of a three-year-old male enrollee has requested for emergency services for treatment of his fever. Findings:  The physician reviewer found that it is very concerning when a toddler with a history of URI symptoms develops new-onset fever/vomiting/diarrhea. This constellation of symptoms could represent a new illness (urinary tract infection, gastroenteritis) or a complication of the original illness (otitis media, pneumonia). A parent cannot be expected to differentiate between these two possibilities. In addition, tachycardia without fever, combined with decreased urine output, are concerning for significant dehydration. Parents are generally instructed by their pediatricians to bring a child to immediate medical attention when they are not drinking and they are not urinating normally. In summary, it was appropriate for the parent, a prudent layperson, to seek immediate medical attention for this small child at the closest ER.
Appeal type: Urgent Care
Decision: Upheld

A 38-year-old female enrollee has requested  emergency services for treatment of her rash.  Findings:  The physician reviewer found that review of the submitted clinical documentation demonstrates that a prudent layperson would not have sought immediate medical attention on the date in question. In this case, the patient presented ambulatory with a pruritic rash for several days. The patient reported to the triage nurse that her eyes were swollen. However, the photos provided for review show what appears to be mild lid edema. In addition, the patient was not in distress. Multiple entries in the record note that she was not having any difficulty breathing or swallowing. The patients symptoms were not acute in onset. She had experienced similar symptoms in the past. A prudent layperson would not have sought medical attention on the date of service in question because the absence of immediate medical attention could not reasonably be expected to result in placing the patients health in serious jeopardy. All told, the patients symptoms would not lead a prudent layperson to believe their health to be in imminent danger. In sum, the patients symptoms did not meet prudent layperson criteria for emergency care.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Synvisc-One (hyaluronan) injection in both knees.An exhaustive review of the current medical literature pertaining to viscosupplementation reveals mixed results. Evidence from eight systematic reviews and six randomized controlled trials indicates that although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. Different studies have tried mixing hyaluronic acid with corticosteroids, platelet-rich plasma, and other agents to make it more effective. The current evidence is limited, and guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate that the evidence is not conclusive. In light of the foregoing, viscosupplementation can only be recommended in individuals with a history of lasting benefit from prior injections, and in carefully selected cases where everything else has been tried, and the options are limited. In this patients case, prior viscosupplementation was beneficial. Furthermore, the patients options are limited. The alternative is total knee arthroplasties of both knees. Therefore, Synvisc-One (hyaluronan) injection in both knees is medically necessary for 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 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

A 62-year-old male enrollee has requested epidural injections for treatment of his lumbar degenerative disc disease and left sided radiculopathy. Findings:  The physician reviewer found that the patients medical records shows he received an initial epidural steroid injection and had a 90% reduction in his pain. The patient had two additional epidural steroid injections, however they were not medically necessary for the patients medical condition because the patient reported a great reduction in pain following the initial injection. There is inadequate medical evidence that repeated epidural steroid injections are required to achieve pain reduction greater than 90%. Thus, the two additional epidural injections performed following the initial treatment were not medically necessary for the patients medical condition. Although the patient reported a 90% reduction in pain following the initial injection, the scientific data does not support repeated epidural steroid injections over a single successful injection.