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

A 41-year-old female enrollee has requested a gastrointestinal (GI) tract capsule endoscopy for evaluation of her medical condition of chronic diarrhea.  Findings:  Two physician reviewers found that as constructed by the American Society of Gastrointestinal Endoscopy (ASGE), the indications for capsule endoscopy include: evaluation of obscure gastrointestinal bleeding not identified by colonoscopy and upper GI endoscopy; iron deficiency anemia; to confirm the diagnosis of Crohns disease when suspected; in the evaluation of suspected celiac sprue when the diagnosis cannot be confirmed by conventional methods; suspected small bowel malignancy; and in the evaluation of polyposis syndromes. Overall, this patients medical records do not provide clinical justification for the requested capsule endoscopy. The laboratory results are not consistent with a chronic inflammatory process, such as Crohns disease. Moreover, the provider did not indicate any suspicion of Crohns disease or any of the other indications for a capsule endoscopy as delineated by the ASGE. Thus, the requested diagnostic procedure is not likely to be more beneficial than conventional modes of evaluating this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 45-year-old male enrollee has requested for an MRI of the back for evaluation of his low back pain. Findings:  The physician reviewer found that there is no documentation of conservative therapy, including physical therapy.  There is no clinical concern of infection or metastatic disease.  There is no history of recent trauma.The current medical evidence does not support the requested diagnostic procedure in this patients case.  As there is no documentation of a recent trial of conservative therapy, and this patient has uncomplicated back pain, the requested MRI of the back is not medically indicated in this patients case.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a four-year-old male who stutters. He has participated in school-based group therapy as well as individual private speech therapy starting in May 2006. As of July 2006 the patient had success working at the three-word imitated sentence level. A request has been made for reimbursement for the private therapy as well as prospective authorization for continued therapy. The Health Plan has denied this request citing a lack of medical necessity.The Health Plans denial should be upheld. Disfluent speech at three to four years of age is usually of short duration. There is no clinical documentation to suggest that the patients speech difficulties are associated with a medical problem. Therefore, there is no evidence to demonstrate that speech therapy is medically necessary for this patient. As such, I have determined that the therapy at issue was/is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

A 48-year-old male enrollee has requested for Provigil for treatment of his excessive daytime sleepiness and fatigue secondary to HIV, Hepatitis C, and major depressive disorder.   Findings:  The physician reviewer found that Provigil works well for him and keeps him active and highly functional; thus, its use in this setting is a prudent, practical off label application justifying its coverage as medically necessary. It is noted that clinical psychiatrists throughout the United States have discovered similar clinical uses of the drug in treatment of patients with symptoms such as those experienced by this patient.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee is requesting coverage of residential services.The diagnoses are opioid use disorder severe, sedative hypnotic use disorder severe and major depression recurrent in remission. The enrollee underwent brain surgery and has had continued seizures since that time. The enrollee has a history of medication noncompliance, and a history of multiple overdoses; most recently, the patient impulsively ingested two bottles of Seroquel. There is mention of discharge from mental health inpatient, with stepdown to partial hospitalization program (PHP).On admission to residential, and thereafter, the patient's withdrawal symptoms were not of a severity necessitating 24/7 monitoring as evidenced by her COWS and CIWA scales. The patient denied suicidality or homicidally, and was not depressed. The enrollee clearly showed poor impulse control, however this is not a criterion in and of itself for residential admission. There were no emotional or behavioral factors necessitating residential level of care. The enrollee was medically and psychiatrically stable. The patient had some social supports available in that the discharge plan was for the support system members. The patient had an outpatient therapist. Based on the findings treatment could have been rendered in an ambulatory setting, therefore residential level of care was not medically necessary.Final Result: The reviewer determined that the requested services was 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.
Appeal type: Experimental/Investigational
Decision: Upheld

A 27-year-old female enrollee requested genetic testing (whole exome sequencing) (CPT codes 81402, 81403, 81404, 81405 and 81406) for medical evaluation of the enrollees medical conditions.  Findings:  Two physician reviewers found that the requested whole exome sequencing is not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The medical literature does not support the requested services in this clinical setting. Glissen and colleagues applied whole genome sequencing to 50 patients with severe intellectual disability and their unaffected parents. The authors reported a high yield of positive findings on whole genome sequencing in patients with intellectual disability and all of these patients also had whole exome sequencing with negative results. Moreover, it is unlikely that the patients multiple medical issues can be fitted into a unifying cause of disease. Therefore, the requested services are not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned

A 59-year-old enrollee who has been diagnosed with left knee patellofemoral chondromalacia. In October of 2019, the patient reported left knee pain. She has been treated with physical therapy and cortisone injections, with minor pain relief. The provider noted magnetic resonance imaging (MRI) of the left knee dated September of 2018 revealed moderate grade cartilage fissuring along the median ridge of the patella and central trochlea. The patient was treated with three Euflexxa injections in November 2019. In August of 2020, the patient reported 100% pain relief with Euflexxa injections provided in November 2019. In August of 2020, the patient stated her left knee pain was rated as one out of 10 until two months ago. The provider noted the patient has been treated with prior Monovisc injections. The patient has requested authorization and coverage for a series of three Euflexxa injections for the left knee. The Health Plan denied the request and reported the requested services are not medically necessary for the treatment of this patient. At issue in this case is whether a series of three Euflexxa injections for the left knee are medically necessary for the treatment of the patients medical condition. Review of the current medical literature pertaining to viscosupplementation reveals mixed results. Although viscosupplementation may relieve knee pain in some patients with osteoarthritis, it is unknown which patients will benefit. Considering the foregoing, viscosupplementation can only be recommended for patients with a history of lasting benefit from prior injections and in carefully selected cases when everything else has been tried and the options are limited. In this case, the patient has a history of excellent relief from prior viscosupplementation injections using Monovisc and Euflexxa. Furthermore, the patients options are limited. The patient has tried and failed other conservative options, including corticosteroid injections and physical therapy. A total knee arthroplasty is not an option at this stage. Researchers reported, Patients with patellar chondropathy of grades II or III treated with hyaluronic acid and physical therapy had less pain and better functional results after three and six months of treatment compared to patients undergoing physical therapy alone. The medical evidence supports the requested services in this clinical setting. Therefore, a series of three Euflexxa injections for the left knee are medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for budesonide.According to the American College of Gastroenterology (ACG) guidelines for the treatment of Crohns disease, Controlled ileal release budesonide at a dose of 9 mg once daily is effective and should be used for induction of symptomatic remission for patients with mild-to-moderate ileocecal Crohns disease. Additionally, American Gastroenterological Association (AGA) guidelines for the treatment of Crohns disease state, The adverse effects in both the short and long-term with systematic corticosteroids are substantialbudesonide, however, due to a first-pass metabolism in the liver is better tolerated with fewer adverse effects and no significant alterations on serum cortisol level. Finally, Rezaie and colleagues state that budesonide is effective for the treatment of Crohns disease with less adverse effects than systemic alternatives. In this case, the patient has uncontrolled Crohns disease. According to the medical literature, budesonide is an appropriate treatment for patients with mild-to-moderate ileocecal Crohns disease. Therefore, budesonide 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 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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Acthar gel. Medical literature shows that the available data on IgM nephropathy is based on clinical observations. Medical literature cautioned that mechanistic studies of IgM nephropathy are lacking. Moreover, there is a lack of support in the available clinical guidelines reporting that Acthar gel is safe and effective for treatment of IgM nephropathy. There is data demonstrating that rituximab can lead to remission in IgM nephropathy. Researchers concluded that rituximab is likely a valuable novel therapeutic drug for the treatment of patients with IgM nephropathy. This patients records do not document an adequate treatment course with rituximab. All told, the requested Acthar gel is not medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in internal medicine with subspecialty certification in nephrology 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 58-year-old female enrollee requested authorization and coverage of a power-operated vehicle (POV) for the treatment of cervical stenosis and meningitis.  The health plan denied the enrollees request indicating that a POV is not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer upheld the health plans denial on the basis that the requested equipment is not medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld

An enrollee has requested authorization and coverage for laparoscopic anti-reflux surgery utilizing the LINX Reflux Management System. Scientific evidence via well-designed controlled studies with adequate follow-up, has not demonstrated the safety and efficacy of the LINX procedure for the treatment of patients with gastroesophageal reflux disease (GERD). Evidence arises largely from case series and cohort studies. The pivotal trial that led to the U.S.  Food and Drug Administration (FDA) approval of therapy was a non-randomized, non-blinded, multi-center trial. Direct comparative studies between surgical interventions are lacking to better assess the long-term safety and efficacy of this intervention in patients. As this patient has GERD with atypical symptoms, further work-up might help ascertain the etiology of his condition. The records do not suggest that the patients symptoms would be substantially improved with the LINX procedure. Moreover, the provider noted that the patients symptoms are improved with PPI use. Given these findings, the requested laparoscopic anti-reflux surgery utilizing the LINX Reflux Management System 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 not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewers 1, 2, and 3 are board certified in internal medicine with subspecialty certification in gastroenterology 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

The enrollee is requesting authorization and coverage for custom orthotic shoe inserts. The enrollee has diagnoses of plantar fasciitis, pain in the right foot, neuralgia, and pes cavus. Pain developed gradually several years prior and was rated a 7/10 in severity. Her pain had an aching, dull, sharp, shooting, stabbing, and throbbing quality, radiating into the right hand and to the bilateral feet and legs. Pain medication was partially effective in relieving the pain. The enrollees podiatrist is requesting custom foot orthotics. She indicates the foot pain has more than one cause and the shoe inserts could help to make her daily routine of working and driving more bearable. She is on her feet when she is at work, which is very painful for her. The enrollee indicates she would rather try inserts than add more medications to her routine. She has liver issues and worries about medication impacts. While many studies have been published regarding custom foot orthotics, the results are varied and are either inconclusive or negative.  The role of over-the-counter orthotics for pain relief has been extensively researched. Studies found they can be an effective treatment for pain relief.  There is insufficient evidence in the record of the enrollees trying any such measures. There is no evidence of the use of any conservative measures prior to the recommendation of the custom orthotics.Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The clinical reviewer is board certified in podiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Zepatier (elbasvir grazoprevir tablets 50-100 mg) for 12 weeks. Findings:  The physician reviewer found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America, all patients with chronic hepatitis C should be treated (except those with limited life expectancy due to non-liver-related conditions), regardless of fibrosis stage. The guidelines recommend that treatment-naive, genotype 1a patients should be treated with Zepatier for 12 weeks when NS5A resistance is not found.  These guideline recommendations are based on clinical trial results showing a 99% cure rate when NS5A resistance is absent.  However, Zepatier is significantly less effective when NS5A resistance is present, and a different regimen is needed (Zepatier and ribavirin for 16 weeks). For these reasons, although hepatitis C treatment is needed, treatment with Zepatier for 12 weeks is not medically necessary for the treatment of this patient due to lack of NS5A resistance testing. Final Result: The reviewer determined that the requested medication regimen is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The physician 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested neuropsychological testing for evaluation of her medical condition. Findings:  The physician reviewer found that the clinical records provided do not demonstrate the medical necessity for neuropsychological testing at this time. According to the records, previous psychological testing from childhood and adolescence show diagnoses of dyslexia, disorder of written expression, expressive language disorder, and attention deficit hyperactivity disorder (ADHD). There was no documentation submitted to show that the patient experienced any cognitive deficits requiring further work up. Furthermore, the patients record does not show that she suffers from any conditions requiring differentiation via neuropsychological testing. She has no psychiatric diagnoses other than ADHD.  In sum, the requested neuropsychological testing is not medically necessary for this patient.  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 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: Upheld

Nature of Statutory Criteria/Case Summary: The patients parent has requested reimbursement for neuromuscular reeducation physical therapy. There is inadequate evidence in the published medical literature to support the use of neuromuscular reeducation physical therapy over other forms of physical therapy in the treatment of young patients with global developmental delay. Studies addressing physical therapy in young patients with severe global developmental delay are limited. Reporters reviewed 846 articles investigating motor skill programs for young patients with developmental coordination disorder. The authors concluded that, no large-scale multisite randomized control trial (with adequately blinded assessors) has been conducted in relation to any motor skills intervention intended to remediate the impact of developmental coordination disorder. Overall, there is a lack of data to support neuromuscular reeducation physical therapy for the treatment of this patients global developmental delay. For these reasons, the neuromuscular reeducation physical therapy was not medically necessary for this patient.  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 neurology with special qualification in child neurology 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:  Two physician reviewers found that the current medical evidence supports the services at issue in this patients case.  According to Skaane and colleagues, the use of mammography plus tomosynthesis in a screening environment resulted in a significantly higher cancer detection rate and enabled the detection of more invasive cancers. Ciatto and colleagues noted that integrated two-dimensional and three-dimensional mammography improves breast cancer detection and has the potential to reduce false positive recalls.  The medical literature supports the use of breast tomosynthesis over conventional mammogram due to improved cancer detection rate.  Therefore, breast tomosynthesis was likely to have been more effective than other methods of evaluating this patient.  Final Result: Two 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.