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

A 50-year-old male enrollee has requested Lyrica for treatment of his complex regional pain syndrome.  Findings:  Two physician reviewers found that the review of the medical documentation indicates the patient has a history of complex regional pain syndrome (CRPS). He has been maintained on Lyrica 50 mg, 3 times per day, and has reported a positive response with decreased pain. Per the medical records, he tried and failed gabapentin 800 mg, 3 times per day. He has also used narcotic analgesics for pain control. CRPS is a chronic progressive disease characterized by severe pain, swelling and skin changes (Wallace and Staats). There is no specific cure and the exact cause is currently unknown. Precipitating factors include injury and surgery, although there are cases that have no demonstrable injury to the original site. Treatment involves medications including anti-depressants, non-steroidal anti-inflammatory drugs (NSAIDs), gabapentin, pregabalin, and alpha-or beta-adrenergic blocking compounds, in addition to opioids. Other therapies include physical and occupational therapies, local anesthetic blocks/injections, spinal cord stimulators, and sympathectomy. CRPS can strike at any age, but the mean age at diagnosis is 42 (Goroll and Mulley). The pain of CRPS is continuous and may be heightened by emotional or physical stress. Moving or touching the limb is often intolerable and the symptoms vary in duration and severity. There are no specific laboratory tests that can verify the existence of CRPS however tests such as thermogram, three phase radionuclide bone scanning, and sympathetic blocks, can be useful in providing evidence for the diagnosis. This patients documentation supports that he has had a positive response to Lyrica therapy for management of his diagnosis of CRPS. Moreover, a review of the scientific data has demonstrated that Lyrica has resulted in positive outcomes for patients in the treatment of CRPS. As this patient has already experienced a response to Lyrica after failing to achieve relief of symptoms with gabapentin, Lyrica is likely to be more beneficial for treatment of his condition than any standard alternative.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 13-year-old male who has been having difficulty in school. As a result he underwent a battery of tests including expressive and receptive language, standard air, and central auditory testing (a SCAN-A test). The results of the SCAN-A test were abnormal indicating a central auditory processing disorder. The Health Plan has denied reimbursement for the SCAN-A test.Central auditory processing testing such as the SCAN-A test is a widely accepted tool for evaluating central auditory processing disorders or dysfunction. Based upon the information submitted, this patient was exhibiting signs and symptoms demonstrating a need for central auditory processing evaluation. Given the patients history the results of the SCAN-A test whether normal or abnormal would have had an impact on the patients treatment plan. Based upon the information set forth above, I have determined the SCAN-A test at issue was indicated and medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

A 41-year-old male enrollee has requested for thoracic laminectomy for placement of spinal cord stimulator paddle electrodes and placement of implantable pulse generator for treatment of his pain. Findings:  The physician reviewer found that thoracic laminectomy for placement of spinal cord stimulator paddle electrodes and placement of implantable pulse generator is not medically necessary for treatment of this patients medical condition. Anticonvulsant, antidepressant, beta blockers and Triptans are considered safe and efficacious therapies for chronic headaches. Neuropathic/radicular pain syndromes are presently the main focus in successful trials of spinal cord stimulation. This patient appears to be presenting with a more complicated picture of headaches not associated with neuropathic pain syndromes. In the absence of clinical data demonstrating the effectiveness of spinal cord stimulation in the treatment of chronic headaches, the requested services are not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a two-year-old male has requested speech therapy for treatment of his speech delay.  Findings:  The physician reviewer found that based on review of the available records, this two-year-old male is mildly speech delayed. Two possible etiological factors could be related to this delay and include: that he is maintained on an anticonvulsant which may minimally affect his speech development; and that both English and Spanish are spoken in the home and he was tested with English language scales. However, his delay is only mild and both speech therapists indicated that the mild delay of several months was due to a developmental delay, which generally does not require intervention for the patient to develop normal speech. In the medical literature, Emmanuel and colleagues evaluated the accuracy of testing two-year-old children. The authors validated the accuracy of testing two-year-olds and indicated that testing is highly predictive of whether a patient needs speech therapy and if they would benefit from therapy. Since this patient was evaluated by two individual speech therapy evaluators two months apart, and both providers used standardized tests to arrive at the same receptive and expressive speech conclusions, the testing should be considered valid. Since neither speech therapist recommended speech therapy, it is not medically necessary for this patient to receive speech therapy.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:   An enrollee has requested inpatient psychiatric hospitalization services for treatment of his medical condition.  Findings:  The physician reviewer found that review of the submitted documentation demonstrates the patient presents with a history of serious and persistent mental illness which has been poorly controlled, thus necessitating intensive services including hospitalizations. The record documents complex psychiatric comorbidity and recurrent suicidality. However, the patient was improving during the admission and it appeared that the acute psychiatric syndrome that had prompted the admission was resolving. He was actively engaged in treatment. A discharge planning meeting was held but limited records have been provided beyond that date. Overall, while the patient had progressed during the hospital stay, he had not yet consolidated the treatment gains necessary to successfully follow through with treatment in a less restrictive setting. Based on the documentation provided, it would have been appropriate and consistent with accepted medical practice to retain this patient at an acute level of care initially, at which time he could have been appropriately treated at a less intensive level of care.  Final Result: The reviewer determined that a portion of the services was medically necessary for treatment of the patients medical condition. Specifically, inpatient psychiatric hospitalization initially was medically necessary. Therefore, the Health Plans denial should be partially overturned.  Credentials/Qualifications:  The reviewer is board certified in psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Findings:  The physician reviewer found that The patient has requested authorization and coverage for the Libre 14-day reader and sensor. Olczuk and Priefer report that self-monitoring of glucose allows patients with diabetes mellitus to take control of their disease and thus directly affect the outcomes related to it. Zheng and colleagues note that continuous glucose monitoring (CGM) systems may be clinically valuable due to their accuracy and convenience and may promote glycemic and weight control, helping to reduce the risk of hypoglycemia and hyperglycemia. The authors further note that CGMs are a useful tool for real-time monitoring of blood glucose and for assessing the impact of treatment and lifestyle on daily changes in blood glucose levels. Given that current medical literature supports the safety, efficacy, and accuracy of CGMs, the requested equipment is medically indicated. Therefore, the Libre 14-day reader and sensor are medically necessary for the 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.
Appeal type: Medical Necessity
Decision: Upheld

A 51-year-old female enrollee has requested the medication Lyrica for the treatment of her fibromyalgia.   Findings:  The physician reviewer found that Lyrica is FDA approved for diabetic neuropathy and post herpetic neuralgia pain. It is not FDA approved for chronic fibromyalgia pain. Generally accepted off-label uses of Lyrica include primarily neuropathic type pain symptoms. The condition of fibromyalgia does not meet any of the aforementioned FDA or generally accepted off label uses of Lyrica.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for GeneSight genetic testing. Findings:  The physician reviewer found that current peer-reviewed medical literature, GeneSight genetic testing based on investigating polymorphisms on cytochrome P450 which are unique for each individual, is medically necessary for evaluation of this patient. The GeneSight genetic test is personalized to an individual patient to help assess the rate of drug metabolism and guide medication regimens and dosing (Garcia-Gonzalez, et al.; Daly). Dawes noted that, pharmacogenetic information has been introduced in response to the unpredictability of medication, the high number of adverse drug events, and lack of drug effectiveness. Per the author, Each pharmacogenetic variant may affect the metabolism of several medications used in primary care, in addition to the antidepressant and anti-anxiolytic medications. Given this support, the requested GeneSight genetic testing is indicated for this patient with a history of developmental and behavioral health issues. Moreover, the requested GeneSight genetic testing is in accordance with the generally accepted standards of mental health and substance use disorder care, clinically appropriate in terms of type, frequency, extent, site, and duration and not primarily for the convenience of the patient or provider. All told, the requested GeneSight testing is medically necessary for this patient. Final Result: The reviewer determined that the requested services are medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in clinical genetics and genomics 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 cochlear implants for treatment of the enrollees left-sided hearing loss. Findings:  The physician reviewer found that the current medical literature reports some benefit to patients with SSD after cochlear implantation in the affected ear, but most of the reports refer to a small number of clinical cases. Colleagues reported that 45% of patients reported tinnitus suppression following cochlear implantation. Other articles report comparable results, but state that information regarding long term outcomes is lacking and that further studies are necessary to document the degree of improvement with cochlear implantation in SSD. Colleagues reported that Although some studies have shown encouraging results on cochlear implantation and SSD, all fail to provide a high level of evidence. Larger studies are necessary to define the tangible benefits of cochlear implantation in patients with SSD. Similarly, colleagues reviewed the evidence and stated that There are no high-level-of-evidence studies concerning cochlear implantation in patients with SSD. Based on the current level of medical literature, the request for cochlear implant has not been established as medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the requested service 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 otolaryngology 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 17-year-old female enrollee has requested residential treatment center (RTC) services for the enrollees behavioral health issues.  Findings:  The physician reviewer found that the patients treating provider described her positive response to antidepressant medication. The providers notes dated subsequently document the absence of further suicidal ideation. In addition, the patient was no longer engaged in self-harm behaviors. The records also indicate that she was actively involved in her treatment. There is no indication in the medical records of any depressive symptoms, self-harm behaviors, aggression or other behavior that continued to require treatment in a 24-hour RTC level of care environment. After approximately one month of treatment, the records indicate that she had greatly improved and no longer required the intensity and monitoring provided in a RTC 24-hour facility. She no longer met any standardized criteria for continued stay and could have safely been treated at a less intensive level of care. Therefore, the services provided from the time frame specified were not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for physical therapy and occupational therapy in the home setting. Findings:  The physician reviewer found that Prader-Willi syndrome is a genetic disorder characterized by early feeding difficulties and failure to thrive, as well as significant hypotonia. Hypothalamic dysfunction may be the basis for short stature and hypogonadism. It may also contribute to problems with temperature regulation. Later on, hyperphagia leading to obesity and learning disabilities are characteristic. Respiratory problems include obstructive apnea and central hypoventilation and/or apnea. Chronic gastroesophageal reflux and aspiration also contribute to respiratory difficulties. Upper respiratory infections are often more serious than initially expected. This patient has been experiencing significant hypotonia since birth, as evidenced by her feeding difficulties. Because of her hypotonia, she may also have difficulty managing secretions. Because of her age, she is at risk for the myriad of respiratory illnesses currently in play across the country, specifically influenza A, influenza B, respiratory syncytial virus, human metapneumovirus, and the many rhinovirus subspecies. Any of these respiratory viruses could cause severe illness in this patient, including bronchiolitis and pneumonia. Limiting her exposure is important in maintaining her health in general, and her feeding regimen specifically. Therapy gyms that service young children present great exposure risk. For the duration of the respiratory viral season (at least through June to cover influenza B), home based therapy is medically necessary and appropriate. All told, physical therapy and occupational therapy in the home setting is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested therapy 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 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: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The representative of an enrollee has requested reimbursement the hospital stay provided. Findings:  The physician reviewer found that Based on the clinical documentation submitted for review, the medical necessity for the services at issue have not been established. The patient remained stable during the hospital stay during the dates of dispute and  was no longer requiring parenteral medication. Her blood pressure, pulse and oxygen saturations were stable. The patient was able to take oral nutrition and was voiding without complications. She was ambulatory.  The patient was no longer monitored by daily laboratory studies or receiving imaging studies. The documentation supports that the patient was stable for discharge . Accordingly, the hospital stay provided during the dates of dispute was not medically for treatment of the patients medical condition. Final Result: The reviewers 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: Physician reviewer is board certified in internal 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

Nature of Statutory Criteria/Case Summary: The parent an enrollee has requested reimbursement for continued psychiatric residential treatment provided for treatment of the enrollees behavioral health condition.  Findings:  The physician reviewer found that the patient meets clinical criteria for continued stay at the residential level of care. Although the patient was not a serious risk of harm to herself or others during the dates in dispute, this is not the only criterion for continued treatment at the residential level of care. An important consideration for discharge is the ability of the patient to transition to a lower level of treatment without risk of regression and readmission. In this case, the notes show that even in the secure environment of the residential treatment center, the patient experienced regression during treatment. In addition, she had continued intermittent suicidal thoughts expressed to her provider on multiple occasions. The records demonstrate that the patient was not psychologically stable enough to be discharged to a lower level of care without a serious concern that she would regress and harm herself. Final Result: The reviewer determined that the services at issue were medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The physician reviewer is board certified in psychiatry with sub-specialty certification in child and adolescent psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 48-year-old female enrollee has requested extracorporeal shockwave therapy (ESWT for treatment of her plantar fasciitis. Findings:  Three physician reviewers found that  ESWT remains experimental for the treatment of chronic plantar fasciitis. There is no class I data clearly supporting the application of this technique. A review of the current literature did not identify a standardized protocol or a general consensus as to the recommended frequency, mode of delivery or type of anesthesia for ESWT. There are still questions regarding the efficacy of ESWT and long-term outcomes in the treatment of chronic plantar fasciitis are uncertain.
Appeal type: Experimental/Investigational
Decision: Upheld

A 63-year-old male has requested radiofrequency ablation of the sacroiliac (SI) joints and lateral branch nerves for treatment of his bilateral SI joint dysfunction.   Findings:  Two physician reviewers found that the patient presents with low back pain. The patient has a history of fusion at S1 and bilateral hip replacement. The record indicates the patient has a history of back and buttock pain as well as anterior thigh numbness. A computed tomography (CT) guided medial branch injection demonstrated mild bilateral anterior lipping at the sacroiliac (SI) joints with mild scoliosis on the iliac side of the SI joint bilaterally. One provider reports the patients pain was dramatically improved with spinal facet joint injections, but the relief was transient and the patient now requires radiofrequency ablation (RFA) at the same facet joints. Another provider states that in patients who receive adequate, but short-term relief benefit from steroid injections into the SI joint, it is reasonable to pursue RFA of the SI joint for long-term benefit. Radiofrequency ablation of the SI joint is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The majority of peer-reviewed literature supports the efficacy of radiofrequency neurolysis in the treatment of chronic spinal pain due to facet pathology as long as the patients are appropriately selected. In reviewing the medical records the patient had a spinal fusion in the area to be treated with RFA. The medical literature does not support the efficacy of RFA at levels in which the medial/lateral branches are already disrupted such as that which may occur in spinal fusions. As noted by Aydin and colleagues, Further standardization of RFA lesion techniques needs to be established, coupled with prospective randomized controlled trials.