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

Findings:  The physician reviewer found that The patients parent has requested authorization and coverage for speech therapy services. The available records document that this patient has severe expressive, receptive and pragmatic language impairment due to autism spectrum disorder. Although the patient scored below the first percentile for expressive and receptive language on the Oral and Written Language Scales Second Edition (OWLS-2), speech therapy reports indicate progressive improvement in intelligibility of speech. This is despite the patient missing several months of speech therapy and having predominantly telehealth sessions during the pandemic. The provider noted that the patient has met several goals, and the patient has shown progress towards other goals. The patients mother reported a regression of language skills and increased frustration since speech therapy has stopped. The patients mother has requested speech therapy services for the patient. Baumer and Spence recommend treatment of patients with autism spectrum disorder involving intensive behavioral therapy and educational programming along with traditional ancillary services such as speech, occupational, and physical therapies. The American Academy of Pediatrics (AAP) stated that, All children with autism spectrum disorder should have documentation of specific coexisting speech and language diagnoses so that appropriate intervention might be provided. Speech-language therapy is the most commonly identified intervention provided for children with autism spectrum disorder. Bellomo and colleagues discussed the challenges that children with autism have faced during the pandemic. The authors concluded that, Children with autism spectrum disorder are a particularly vulnerable population in the pandemic due to the potential for exacerbation of autism spectrum disorder symptoms, limited access to therapy, and the overwhelming responsibility placed on their caregivers. Moreover, the requested speech therapy services are 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 are not primarily for the convenience of the patient or provider. For these reasons, the requested speech therapy services are medically necessary for treatment of this patient. 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.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a 10-month-old female enrollee has requested  the formula supplementation Similac Alimentum for treatment of the enrollee, who has a history of constipation. Findings:  The physician reviewer found that the submitted documentation does not include diagnostic tests that substantiate the diagnosis of lactose intolerance. This patient has a history of constipation and eczema. There is no indication for using a hydrolyzed formula to treat constipation for infants less than one year of age, per the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition guidelines. Of note, there is no mention of constipation or lactose intolerance in office visit notes within the past seven months. The medical documentation also notes eczema. There is no documentation that a trial of the requested formula will improve this patients eczema. In this patients case, the formulary supplementation Similac Alimentum is not medically indicated.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Monovisc injection in the right knee. This patient presents with chronic right knee pain due to osteoarthritis. She has tried and failed treatment with non-steroidal anti-inflammatory drugs (NSAIDs), topical analgesics, three months of physical therapy, and corticosteroid injections. Her provider has documented prior benefit from viscosupplementation. The provider recommended an injection of Monovisc for the right knee. Evidence from systematic reviews and randomized controlled trials indicate that although viscosupplementation may relieve knee pain in some patients with osteoarthritis, data has not established which patients will benefit. Guidelines from the American Academy of Orthopedic Surgeons (AAOS) indicate that the data on safety and efficacy of viscosupplementation remain inconclusive. As such, the AAOS does not currently recommend viscosupplementation as standard treatment for osteoarthritis of the knees. Per the AAOS, viscosupplementation is reserved for patients with a history of lasting benefit from prior injections and in cases where the remaining options are limited. This patients records indicate that she previously experienced adequate positive benefit from prior viscosupplementation injections. Furthermore, the patients remaining treatment options are limited as she has tried and failed conservative treatment modalities. For these reasons, the requested Monovisc injection in right knee is medically necessary for treatment of this patient. 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 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 31-year-old male enrollee has requested OxyContin 80mg. for treatment of his sickle cell anemia.  Findings:  The physician reviewer found that Baron and McDonald 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, most 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 effects of opioid-induced hyperalgesia. High dose opiates may also cause adverse outcomes and therefore the patients requested authorization and coverage for OxyContin 80mg twice per day is not indicated. Ballantyne and Mao 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. Therefore, it is in the patients best interest to wean off all opiates and participate in adjunctive therapy including non-narcotic medications, physical therapy, massage therapy, or cognitive behavioral therapy, in order to address his chronic pain. Consistent with these findings, the requested medication is not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:   An enrollee has requested inpatient psychiatric hospitalization for treatment of his behavioral health condition.  Findings:  The physician reviewer found that the medical records submitted for review support the medical necessity of inpatient psychiatric hospitalization. In this case, the patient is plagued with co-occurring substance dependence and a serious formal thought disorder, which as a class represents the most severe of psychiatric illnesses. Discharging any patient prematurely under such circumstances would be inconsistent with good medical practice, thus a conservative hospitalization was to be expected. Considering the longitudinal history of the case, the patient had not yet consolidated the treatment gains necessary to succeed outside the hospital and treatment in a less restrictive setting at the time would have been inadequate. There was no reasonable discharge plan at the time. In sum, considering the case in its entirety within the context of current practice guidelines and relevant peer-reviewed literature, the inpatient services in dispute were for active treatment and reasonably expected to improve the patients condition and prevent a more serious episode of illness. Additionally, the admission was successful in that the patient was directly transferred to a long-term unit without interruption of care.  All told, the services at issue were safe, appropriate and medically necessary.   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 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: Overturned

An enrollee has requested reimbursement for the digital breast tomosynthesis performed. Findings:  The physician reviewer found that tomosynthesis is a technique that was developed as a problem solving adjunct to routine mammography. In this case, the patient has 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. Accordingly, the digital breast tomosynthesis performed was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: The reviewers determined that the diagnostic procedure at issue was 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: the physician reviewers are board certified in diagnostic radiology 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 mother of a three-year-old female enrollee requested authorization and coverage of a follow up speech assessment of the enrollee. The Health Plan denied the request.  One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested assessment is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for anesthesia services. Monitored anesthesia care is warranted in prolonged or painful procedures such as complex polyp resections, endoscopic retrograde cholangiopancreatography, or other biliary procedures, endoscopic dilation, or endoscopic resection. Additionally, monitored anesthesia care may be necessary in patients with failed history of moderate sedation for the procedure or psychological impediments to cooperation. The provided records do not support any of these criteria, or other criteria in the literature, such as difficult intubation, airway obstruction, allergies to sedation medications, chronic alcohol or illicit drug use resulting in increased tolerance to sedation medications, age greater than 70, pregnancy, increased aspiration risk, ASA class III or higher, or morbid obesity. The submitted records do not support the medical necessity of monitored anesthesia care over short-acting sedation in this case. Therefore, anesthesia services were not medically necessary for the treatment of 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 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 reimbursement for chiropractic services and prospective authorization and coverage for future chiropractic services.The submitted documentation fails to demonstrate the medical necessity of the services at issue. According to a systematic review, the results from 19 clinical trials did not support the existing evidence for the clinical value of Eastern or Western manipulative therapy for neck pain of short-term follow-up according to minimally clinically important difference of the Visual Analogue Scale. In this case, the diagnosis submitted by the chiropractor is segmental dysfunction of the cervical and thoracic spine. Records indicate that the patient reported neck and back pain. Notes from x-rays showed that there were mild chronic degenerative changes with no acute findings in the lumbar spine and mild asymmetric degenerative changes of lower lumbar posterior facet joints. However, the evidence from medical literature does not support a significant benefit from manipulation therapy in this setting. Thus, chiropractic services provided and onward were not and are not medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in chiropractic 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:  An enrollee has requested spinal epidural injections for treatment of her medical condition.  Findings:  The physician reviewer found that there is sufficient support for the requested services in this clinical setting.  This patient has signs and symptoms of sciatica.  Epidurals may be appropriate for radiculopathy or sciatica when tumor or non-spine pain origin has been ruled out, and the patient has failed two weeks or more of conservative measures.  In this patients case, there is no tumor or space occupying lesion.  The patient is unable to tolerate physical therapy.  Per the medical records, she continues to experience symptoms.  There is sufficient support for the requested services in this clinical setting.  All told, the requested spinal epidural injections are medically indicated for the treatment of this patient. 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 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: Upheld

Findings:  The physician reviewer found that An enrollee has requested reimbursement for lipoprotein testing (CPT 83704 Cardio IQ Advanced Lipid Panel and CPT 83695 Cardio IQ Lipoprotein Fractionation, Ion Mobility). Findings: Three physician reviewers found the patient has intermediate-high risk of developing symptomatic cardiovascular disease over the next 10 years based on his clinical risk factors. However, he has a very substantial negative risk factor for coronary artery disease given the recent coronary artery calcium score of zero. He has no known history of coronary artery disease and no other clinical risk factors except age and moderate hyperlipidemia. It had already been decided that Crestor would be restarted based on the clinical risk profile and the standard lipid profile testing. In this clinical setting, there was no additional information from advanced lipoprotein testing which would significantly add to risk prognosis based on current guidelines and available data. This is especially true in this clinical situation, where the treatment decision to use statin pharmacotherapy has already been made. Therefore, lipoprotein testing (CPT 83704 Cardio IQ Advanced Lipid Panel and CPT 83695 Cardio IQ Lipoprotein Fractionation, Ion Mobility) was not likely to have been more effective than other methods of evaluating this patient. Final Result: The reviewers determined that the services at issue were 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: Physician reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in cardiovascular disease and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An female enrollee has requested authorization and coverage for Mekinist for treatment of the enrollees adenoid cystic carcinoma. Findings: The physician reviewer found that adenoid cystic carcinomas are rare cancers usually arising from the salivary glands presenting as oropharyngeal masses, although metastatic presentations have been described.  The tumors can be slow growing, but have a high propensity for recurrence. Mekinist is a newly inhibitor of MEK kinases approved for use in metastatic melanoma with mutant BRAF.  The MEK kinases are within the same pathway as RAS and BRAF. Thus, it is mechanistically appealing to apply Mekinist to tumors with constitutive RAS signaling, such as the tumor in this patients case. A phase I trial in a study showed that Mekinist was tolerated at 2 mg twice daily with responses in patients with diverse cancers.  Recently, it has become important to identify mutations that may be amenable to targeted therapy.  In another study, they performed a study of 86 patients where the progression-free survival on regimen selected by molecular profiling was compared to the progression-free survival on the last chemotherapy regimen. The regimen selected by molecular profiling offered a 27% survival advantage.  There is sufficient support for the requested medication in this patients case. 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 medical oncology 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 patient is a 48-year-old obese female with a history of high blood pressure and sleep apnea. She has a body mass index (BMI) of 35.8. She wishes to undergo weight loss surgery. She has undergone a psychological evaluation and is considered an appropriate candidate for weight loss surgery. The patients comorbidities would not be considered significant at this time. The Health Plan has denied the patients request on the basis that weight loss surgery is not medically necessary for treatment of the patients obesity.With a BMI of 35.8 and her documented comorbidities, the patient does not meet nationally accepted criteria for consideration of weight loss surgery. There is good potential this patient could obtain significant weight loss through conservative measures while avoiding the risks of weight loss surgery. Because this patient has the potential to lose weight through conservative means the benefits of weight loss surgery do not outweigh the risks. Therefore, I have determined the requested procedure is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Apriso 0.375 gm. Findings:  The physician reviewer found that records provided for review document that this patient has a history of ulcerative colitis that has failed to improve with ciprofloxacin and Canasa suppositories. Treatment with Apriso, which is a formulation of mesalamine, has provided the patient with adequate symptom control for the past year. Mesalamine has been demonstrated to be effective for the treatment of ulcerative colitis in randomized double-blind multicenter clinical trials. Studies noted that the various formulations of mesalamine result in release at distinct times and locations in the gastrointestinal tract, which makes each preparation clinically distinct. Specifically, Apriso is different from alternatives such as Asacol, Lialda and Pentasa, as well as their respective generic formulations, each with release in different portions of the gastrointestinal tract and at different pH levels. Changing therapy for this patient is likely to result in inadequate symptom control with a different formulation since the new agent will direct the drug to a different part of the gastrointestinal tract. Additionally, ulcerative colitis flares can be induced by salicylate medications and changing therapies exposes the patient to this risk. Apriso is a recommended medication for the treatment of ulcerative colitis in this clinical setting. Therefore, the requested Apriso 0.375 gm is medically necessary for this patient. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in internal medicine with subspecialty 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.