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

A 63-year-old male enrollee has requested spinal fusion with instrumentation, interbody arthrodesis and decompression for treatment of his multilevel degenerative disc disease.  Findings: The physician reviewer found that at issue in this case is the medical necessity of a posterior fusion procedure from L2-L5.  In the most comprehensive review to date of the medical literature pertaining to lumbar fusion for disc herniation and radiculopathy, Resnick, et al. examined 389 titles and abstracts. References were identified that provided either direct or supporting evidence relevant to the use of fusion as a treatment for lumbar disc herniations. These papers were pulled and reviewed, and relevant references from their bibliographies were identified.  Neither treatment standards nor guidelines could be formulated due to a lack of high quality studies. Instead, five treatment options were identified as follows: 1) Lumbar spinal fusion is not recommended as routine treatment following primary disc excision in patients with a herniated lumbar disc causing radiculopathy. 2) Lumbar spinal fusion is recommended as a potential surgical adjunct in patients with a herniated disc in whom there is evidence of preoperative lumbar spinal deformity or instability. 3) Lumbar spinal fusion is recommended as a potential surgical adjunct in patients with significant chronic axial low-back pain associated with radiculopathy due to a herniated lumbar disc. 4) Reoperative discectomy is recommended as a treatment option in patients with a recurrent lumbar disc herniation. 5) Reoperative discectomy combined with fusion is recommended as a treatment option in patients with a recurrent disc herniation associated with lumbar instability, deformity, or chronic axial low-back pain. Option #1 would argue against a fusion in this patient as he would be undergoing a primary disc excision at the L3-4 level. Option #2 also argues against a fusion as the patient does not have evidence of lumbar spinal deformity or instability at any level. Option #3 could possibly apply to this patient at the L3-4 level, but the disc herniation is on the left paramedian and the patients leg complaints are on the right.  In addition, there are no documented objective findings consistent with a left L4 radiculopathy and there are also no significant disc herniations at the other proposed fusion levels. Finally, options #4 and #5 do not apply to this patient as he has not as yet had a primary surgery. Based upon the information set forth above and available data, the requested surgery is not medically indicated for this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

A 49-year-old female enrollee requested authorization and coverage of botox injections for the treatment of migraine headaches.  The health plan denied the enrollees request indicating that the requested treatment is experimental.Three physician reviewers performed an experimental/investigational Independent Medical Review.  Each of the three physician reviewers concluded that botox injections are not likely to be more beneficial for treatment of the enrollees migraine headaches than any available standard therapy.  Because all three physician reviewers concluded that the requested treatment is not likely to be more beneficial for treatment of the enrollees medical condition than any available standard therapy, the review organization upheld the health plans denial.
Appeal type: Medical Necessity
Decision: Overturned

A 76-year-old male enrollee has requested for Lyrica for treatment of his back pain. Findings:  The physician reviewer found that Lyrica is a calcium-channel modulator which has been approved for the management of neuropathic pain due to diabetic neuropathy, post-herpetic neuralgia and fibromyalgia. It has been used off-label for many other neuropathic pain conditions, including post-laminectomy pain syndrome.
Appeal type: Urgent Care
Decision: Upheld

A 49-year-old female enrollee has requested emergency services for the treatment of her medical condition. Findings:  The physician reviewer found that at issue in this case is whether a prudent layperson in the patients circumstances would believe she was experiencing an emergency medical condition. California law defines an emergency medical condition as 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: (1) Placing the patients health in serious jeopardy; (2) Serious impairment to bodily functions; (3) Serious dysfunction of any bodily organ or part. Review of the submitted clinical evidence demonstrates that this patient presented with nose pain of one months duration. Her pain was not severe and she was not in distress. She had not sustained any acute injury. She was not short of breath. There was no acute or sudden change in her condition. While the patients symptoms may have warranted a medical evaluation, that service did not need to be provided on an emergent basis. A prudent layperson in the patients circumstances with an average knowledge of medicine would not reasonably expect the absence of emergency care to jeopardize her health.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for acupuncture services. The peer-reviewed medical literature supports a series of six sessions of acupuncture as medically necessary in this clinical setting. Studies reported that at six month follow-up after treatment, the acupuncture group showed a significantly greater improvement in pain intensity compared with the control group. Also, the acupuncture group had consistently better results in range of motion, functional ability, quality of life, and NSAIDs intake than the control group. Acupuncture resulted in effective long-term treatment for patients with shoulder pain. This patient underwent treatment with physical therapy, and oral medication, but continued to be significantly symptomatic. Consequently, an acupuncture trial of six sessions for shoulder pain and functional improvement is supported as medically necessary. Thus, six sessions of acupuncture are supported as medically necessary for treatment of this patients shoulder pain.  Final Result: The reviewer determined that a portion of the services at issue was and is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially 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: Overturned

The parent of a 2-year-old female enrollee has requested authorization and coverage for speech therapy at a frequency of 1.5 hours per week.  Findings:  The physician reviewer found that speech and language development is considered by experts to be a useful indicator of a childs overall development and cognitive ability. In addition, identification of children at risk for developmental delay or related problems may lead to intervention services and family assistance at a young age when chances for improvement are best. As adults, children with phonological difficulties may hold lower-skilled jobs, and show more behavior problems and impaired psychosocial adjustment than their non-impaired peers (Nelson, et al). From this detailed account, speech and language delay must be taken very seriously in young children, because the long-term consequences may be substantial.  According to a meta-analysis of 25 studies, approximately 6% of children have speech and language difficulties (Law, et al). The authors noted that, Whilst most childrens difficulties resolve, children whose difficulties persist into primary school may have long-term problems concerning literacy; socialization; behaviour and school attainment. These reviewers concluded that, overall there is a positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulties. Finally, in a recent review of therapeutic intervention for children with speech and language delay, the authors found that, there are good data available to support the effectiveness of speech-language therapy, particularly for children with primary expressive language disorder (McLaughlin). This patient presents with expressive language delay that significantly impairs her ability to communicate effectively and function socially. Consistent with the support of the efficacy of speech and language therapy in this patient population, the requested speech therapy for 1.5 hours per week is medically necessary and appropriate for this patient to address her speech and language delays.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a transthoracic echocardiogram (CPT 93307). The American College of Cardiology Foundation Appropriate Use Criteria Task Force found that transthoracic echocardiograms were appropriate for re-evaluations of known aortic dilations. In this case, the patient had unequivocal and significant aortic dilation on one imaging study. As progressive aortic dilation is potentially life threatening due to an increased risk of aortic rupture, a repeat transthoracic echocardiogram to assess for any progressive aortic dilation is medically indicated. Therefore, a transthoracic echocardiogram (CPT 93307) is medically necessary for the evaluation of this patient. Final Result: The reviewer determined that the requested services 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 cardiovascular disease 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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for eleven (11) visits for home health services/hospice nurse for treatment of the enrollees cystic fibrosis. Findings:  The physician reviewer found that the documentation states this patient is homebound and requires the services of a registered nurse (RN) who specializes in home health or hospice care to change peripherally inserted center catheter (PICC) line dressing weekly as well as perform standard laboratory testing. Consistent with the Centers for Medicare and Medicaid Services (CMS) recommendations, the requested eleven (11) visits for home health services/hospice nurse are supported as medically necessary for treatment of this patients medical condition. 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 internal medicine with sub-specialty certification in hospice and palliative 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

An enrollee has requested authorization and coverage for a convergent procedure. The patient remains severely symptomatic from his atrial fibrillation (AF), and his ejection fraction is compromised. He has failed two attempts at percutaneous AF ablations with rapid recurrrences, and he has most recently developed persistent AF which has increased his symptomology from the previous paroxysmal episodes. Multiple anti-arrhythmic medications have been utilized over several years with limited success and a number of intolerable side effects. The only other reasonable alternative for the patient might be atrioventricular (AV) node ablation and permanent pacemaker insertion, but given the patients young age and compromised left ventricular (LV) function, this is a less optimal treatment option at this point. As the patient has not responded to several conventional percutaneous ablation procedures or antiarrhythmics, it is now reasonable to consider more complex, invasive and advanced techniques. A convergent surgical/percutaneous hybrid ablation procedure is a very reasonable clinical option for this patient, who has not responded to multiple first line conventional therapies. There is prior published data as to the procedures efficacy in these situations, and very recently additional randomized data has been presented of the Converge trial which showed the superiority of this procedure to conventional ablation, especially when a patient has already failed conventional ablation procedures multiple times and still remains symptomatic. Therefore, the requested convergent procedure is likely to be more beneficial than any available standard treatment for the patients medical condition.Final Result: The reviewers determined that the requested services are likely to be more beneficial than any available standard treatment for the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: Physician reviewers 1 and 2 are board certified in internal medicine, with subspecialty certification in cardiovascular disease. Physician reviewer 3 is board certified in internal medicine, with subspecialty certification in cardiovascular disease and clinical cardiac electrophysiology. All three physician reviewers 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

The patient is a 17-year-old female who has been using methamphetamine since January 2003.  The submitted records indicate the patient has been experiencing mood swings, low academic performance, and low appetite in addition to behavioral and personality changes. The patient and her family started seeking help and treatment for the patients condition in approximately June 2003. It was recommended the patient complete an outpatient chemical dependency program. The submitted records indicate the patient was not motivated to participate in the outpatient program and was uninterested and inconsistent in her treatment. The patient was admitted to a transitional residential recovery services program on 9/8/04. A request has been made for coverage for the patients participation in the transitional residential recovery services program. The Health Plan indicates the services at issue were not medically necessary for treatment of the patients chemical dependency.Review of the submitted medical records and correspondence, reveals the patient is a 17-year-old female who has been using methamphetamine since January 2003. As a result of her drug use she has had academic problems, mood swings, decreased appetite, and personality changes.  The patient was evaluated on 5/4/04, at which time it was recommended she participate in an intensive outpatient program. Based upon the medical records provided, the patient was not engaged, motivated or committed to this program. Her attendance and participation were erratic and inconsistent. Since the patient has not actively participated in outpatient treatment, there is no evidence the services at issue were likely to benefit the patient. Therefore, I have determined that the services at issue were not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for air ambulance transport services. Review of the submitted documentation demonstrates the air ambulance transport services the patient received were not medically necessary. At the times of transport, the patient's medical condition did not require immediate and rapid transportation that could not have been provided by ground transportation. Review of the progress notes prior to both transfers reveals the patient's medical condition was stable for transport. The patients medical conditions were chronic and the patients needs during transport could have been adequately met with ground transportation. The submitted documentation does not reveal any unstable medical issues at the time of either transport which would have posed a threat to the patient's health. As such, the medical necessity of the disputed air ambulance transportation services has not been established.Final Result: The reviewer determined that the services 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 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

An enrollee has requested authorization and coverage for the medication Copaxone. The submitted documentation supports the medical necessity of the requested medication. Colleagues conducted a systematic review of the clinical effectiveness of glatiramer acetate (Copaxone) and found that Copaxone has fewer side effects and has a demonstrated benefit in the treatment of multiple sclerosis. They concluded that compliance with treatment is critical for the best outcome of treatment. They also concluded that Copaxone is an effective treatment for multiple sclerosis due to its side effect profile being better than comparable treatments.In this case, the submitted records reflect that the patient has done well clinically with Copaxone. Copaxone is a Food and Drug Administration (FDA) approved treatment for MS. As noted above, Copaxone has been identified as having a side effect profile that is better than comparable treatments for multiple sclerosis. Concern has been raised about the side effect profile in a generic version of Copaxone, as biologics may differ in physical activity and chemical structure, despite being generic or biologically similar in classification. As such, compliance with any new therapy is unlikely and may lead to poor response and possible failure, if such treatment is instituted. Under these circumstances, Copaxone is medically necessary for the treatment of the patients medical condition.Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in neurology, 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: Experimental/Investigational
Decision: Upheld

The parent of an eight-year-old female enrollee has requested Revlimid for treatment of the enrollees relapsed high-risk stage IV neuroblastoma. Findings:  Three physician reviewers found that the efficacy of the combination of Celebrex and Revlimid for the treatment of advanced neuroblastoma has not been proven in clinical trials. Available medical studies and reports do not show that the regimen is likely to result in an improved outcome in this setting. Revlimid is myelosuppressive and does not show well-documented benefit in neuroblastoma. As such, there is inadequate scientific evidence supporting the efficacy of Revlimid in this setting to support its use in this patient.
Appeal type: Medical Necessity
Decision: Overturned

A female enrollee requested skin tag removal for medical treatment of her skin tag.  Findings:  The physician reviewer found that according to the American Society of Plastic Surgeons, removal of a skin lesions are considered reconstructive surgery and medically necessary for benign lesions associated with itching and enlargement. In this case, the documentation submitted for review demonstrates that the patients skin lesion is enlarging and symptomatic with pruritus. As reasoned above, the patients skin lesion removal is medically necessary and the lesion is an abnormal condition that is associated with symptoms, conferring a functional deficit. Therefore, its removal should be considered medically necessary and reconstructive in nature.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for substance abuse residential treatment center services (RTC) for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found that in this clinical setting, the services at issue were not medically necessary for the treatment of this patient. The patient reported no post-acute withdrawal symptoms.  He was not a danger to himself or others.  His hypertension was stable and controlled on medications. He was psychiatrically stable to the extent that he did not need a 24 hour seven day per week facility to provide the remainder of his care. There was no evidence of a high degree of impulsivity, aggression, agitation, depression, mania, hallucinations, or any other significant symptom that would interfere with his care. He was accepting the principles of treatment and involving himself in his recovery. Given the recidivistic nature of his illness with multiple relapses and subsequent treatments, he already had a groundwork of relapse prevention education. There was no evidence to suggest that additional residential services would have provided further benefit. The patient no longer met American Society of Addiction Medicine clinical guidelines for residential level of care and could have been treated at an ambulatory level of care such as partial hospitalization program or intensive outpatient services with concomitant sober living.  For the reasons stated above, the services at issue were not medically necessary for treatment of this patient. Final Result: The reviewer determined that the the services 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 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.