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

Nature of Statutory Criteria/Case Summary:  An enrollee has requested epidural steroid injections for treatment of her back pain.  Three physician reviewers found that criteria for the use of epidural steroid injections indicates that radiculopathy be documented by physical examination and corroborated by imaging studies and/or electrodiagnostic testing. In this case, there are no reported symptoms of radicular pain which is defined as pain in dermatomal distribution. There are no long tract signs that suggest thoracic myelopathy. There is also no electrodiagnostic testing reported and imaging findings do not describe neural compromise that would corroborate a diagnosis of thoracic radiculopathy. For the reasons provided, the requested thoracic epidural steroid injections are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: Three 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: One reviewer is board certified in physical medicine and rehabilitation with sub-specialty certification in spinal cord injury and pain medicine and is actively practicing. One reviewer is board certified in neurology with sub-specialty certification in pain medicine and is actively practicing.  One reviewer is board certified in physical medicine and rehabilitation with sub-specialty certification in pain medicine and is actively practicing.  All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The parent of a patient has requested reimbursement and prospective authorization and coverage for IOP services. Findings:  The physician reviewer found that the American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists Child and Adolescent Level of Care Utilization System (CALOCUS) provides a reliable framework for determining the appropriate level of care for adolescents needing mental health treatment. Using CALOCUS, treaters score patients on a scale of 1-5 using a six-pronged Dimensional Rating System. The six dimensions include: (1) risk of harm; (2) functional status; (3) medical, addictive and psychiatric comorbidity; (4) recovery environment (a. stressors and (b. supports); (5) treatment and recovery history; and (6) engagement. The composite score is then used to determine the level of care needed. In this case, the patients presents a composite score of 15, which correlates with outpatient services. According to the CALOCUS the patients presentation did not and does not meet the criteria for the requested level of care. Thus, the IOP services were not and are not medically necessary for treatment of this patients behavioral health issues. Final Result: The reviewer determined that the services at issue were not and 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 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: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested neuropsychological testing for evaluation of her cognition.  The physician reviewer found that neuropsychological testing was medically necessary for evaluation of the patients medical condition. According to the American Academy of Clinical Neuropsychologys practice guidelines, distinctive features of neuropsychological evaluations and consultations in assessing brain function and dysfunction include the use of objective neuropsychological tests, systematic behavioral observations and interpretations of the findings based on knowledge of the neuropsychological manifestations of brain-related conditions. In this case, during an appointment with a neurologist, the patient expressed concern of cognitive decline which was impacting her daily functionality. The examination included a Montreal Cognitive Assessment which was suggestive of mild cognitive impairment. Thus, further assessment was reasonable and clinically indicated based on the subjective reports, objective findings and current practice guidelines. Considering that a neuropsychologist often plays an important role in establishing the presence of a neurocognitive disorder, the differential diagnosis, quantification of impairment and cognitive strengths and weaknesses, the testing at issue was safe, appropriate, and consistent with good medical practice. Based on the documentation provided, neuropsychological testing was medically necessary for evaluation of the patients medical condition.  Final Result: The reviewer determined that the testing at issue was 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 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

A 51-year-old male enrollee has requested for azelastine (Optivar) 0.05% ophthalmic solution, Alrex 0.2%, Azelex 20% cream, Lunesta 3mg, and epinastine 0.05% for treatment of his HIV positive. Findings:  The physician reviewer found that the patient has seasonal allergic rhinitis.  The medical records notes that the patient tried fluticasone for approximately 6 to 8 months, with no improvement.  In this clinical setting, azelastine (Optivar) 0.05% ophthalmic solution is medically indicated. The patient was noted to have failed treatment with Patanol, Astelin, and Elestat. In this patients case, Alrex 0.2% is medically necessary.  The provider submitted a prior authorization request for Azelex 20% cream for the treatment of acne rosacea.  The provider noted that there was no available formulary alternative for the treatment of this patient.  Additionally, the provider noted that the patient had already been tried on a multiple medications, which were not of benefit.  Therefore, the clinical documentation supports the medical necessity of Azelex 20% cream in this case.  The documentation fails to demonstrate the medical necessity of Lunesta 3mg and epinastine 0.05%.  The medical records do not provide support for the medical necessity of Lunesta 3mg, and there is indication that the patient has been offered another medication for sleep.  Additionally, there is a lack of documentation supporting epinastine 0.05% in this patients case.  All told, azelastine (Optivar) 0.05% ophthalmic, Alrex 0.2% and Azelex 20% cream are medically necessary.  Lunesta 3mg and epinastine 0.05% are not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

A 44-year-old male has requested Xarelto (rivaroxaban) for treatment of his left ventricular noncompaction cardiomyopathy.  Findings:  The physician reviewer found that left ventricular noncompaction cardiomyopathy (LVNC) is a rare cardiac disorder characterized by a thin, compact, epicardial layer of the myocardium with prominent, deep intertrabecular spaces.  Recent advances in echocardiographic recognition and use of specialized cardiac MRI have resulted in increased awareness of this rare disorder.  Clinical complications of LVNC are variable and range from asymptomatic patients to patients with complications of heart failure, cardiac arrhythmias, and thromboembolic events.  Clinical series have reported thromboembolic complications in 21-38% of patients, including cerebrovascular accidents, transient ischemic attacks, pulmonary embolism, and mesenteric infarctions.  The treatment of LVNC is directed at management of heart failure, treatment and/or prophylaxis for cardiac arrhythmias, and attempt to prevent thromboembolic complications.  Treatment guidelines generally recommend long-term prophylaxis with anticoagulants.Multiple ongoing studies of Xarelto (rivaroxaban) are in progress for assessment of its efficacy in acute coronary syndromes, prevention of stroke in patients with atrial fibrillation, and prevention of venous thromboembolism in hospitalized patients.  This patient has an MRI-based diagnosis of noncompaction left ventricular cardiomyopathy.  His medical records indicate that he is relatively asymptomatic and has no history of cardiac arrhythmias, heart failure, or thromboembolic events.  Current standard cardiovascular practice in the management of this disorder would include oral anticoagulation for prevention of thromboembolic complications.  There is a lack of clinical data supporting the use of Xarelto in this clinical setting.  Alternative management with warfarin anticoagulation would be standard practice at this time.  All told, Xarelto is not medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

A 60-year-old male enrollee has requested Orthovisc injections for treatment of his shoulder pain. Findings:  Three physician reviewers found that in this patients case, the requested Orthovisc injections are not likely to be more efficacious than other available treatment options.  The long-term safety and efficacy of the use of intra-articular injections of viscosupplementation for joints other than the knee has not been demonstrated at this time.  There is a lack of randomized controlled trials supporting the use of Orthovisc injections for the shoulder. Guidelines from the American Academy of Orthopedic Surgeons for the treatment of shoulder arthritis do not recommend injectable viscosupplementation in this clinical situation. The current medical evidence does not support the requested Orthovisc injections in this patients case.  All told, Orthovisc injections are not likely to be more beneficial than other treatment alternatives in this patients case.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested a sleep study performed at a sleep center for evaluation of his sleep difficulties. This patient has some symptoms of obstructive sleep apnea, and testing for this condition was therefore appropriate. However, home testing would not have been adequate in this patients clinical situation. The clinical guidelines recommend home sleep studies for patients with a high pre-test probability for moderate to severe obstructive sleep apnea. In this case, the absence of witnessed apneas placed the patients pretest probability at moderate for mild obstructive sleep apnea. Home sleep studies do not provide the diagnostic sensitivity that is required in these types of cases. As a result, the sleep study performed at a sleep center was medically necessary for thorough evaluation of this patients medical condition.  Final Result: The reviewer determined that the services at issue were 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 neurology with sub-specialty certification in sleep 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 authorization and coverage for gastric bypass surgery for treatment of her morbid obesity.  Findings: The physician reviewer found that based on the documentation submitted for review, the request for gastric bypass surgery is medically necessary for treatment of the patients morbid obesity. The patient meets standard nationally accepted criteria for bariatric surgery including the American Society for Metabolic and Bariatric Surgery guidelines. This patient is an adult with morbid obesity given the BMI of 48.9 kg/m2. In addition, the patient has failed dietary efforts and completed a multidisciplinary evaluation that did not reveal any obvious dietary, behavioral or medical barriers to surgery. As such, the medical necessity for the requested surgery is indicated in this clinical setting.Final Result: The reviewer determined that the requested surgery 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 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 39-year-old female enrollee requested authorization and coverage of laparotomy with possible salpingo-oopherectomy. The Health Plan denied the request indicating that the requested procedure is not medically necessary for treatment of the enrollees abdominal and pelvic pain.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested procedure is not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for Epidiolex. Findings:  The physician reviewer found that the current medical evidence supports the requested medication in this clinical setting. FIRES is a rare childhood epilepsy syndrome that is difficult to treat. This patients clinical history was published in a case series by Gofshteyn and colleagues. The case series included seven children with FIRES who were treated with cannabidiol. This patient was one of six children in the series whose seizures improved in frequency and duration. The medical literature noted cannabidiol (CBD) is one of the cannabinoids with non-psychotropic action, extracted from Cannabis sativa. CBD is a terpenophenol, and it has received a great scientific interest thanks to its medical applications. This compound showed efficacy as anti-seizure, antipsychotic, neuroprotective, antidepressant and anxiolytic. Epidiolex is a pharmaceutical formulation of highly purified CBD in oral solution. It has been demonstrated to be an effective long-term treatment option in Lennox Gastaut syndrome and Dravet syndrome, two forms of intractable generalized epilepsy syndromes in children, and is approved by the U.S. Food and Drug Administration (FDA) for those conditions. The medical literature noted open-label studies with 100mg/ml CBD have provided additional evidence of its efficacy along with an adequate safety profile (including certain drug interactions) in children and young adults with a spectrum of treatment resistant epilepsies. Therefore, Epidiolex is medically necessary for the treatment of 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 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: Medical Necessity
Decision: Upheld

A 43-year-old female enrollee requested authorization and coverage of a referral to an out-of-network chiropractor to provide the Nambudripad Allergy Elimination Technique (NAET) for the treatment of chronic headaches, allergies and sinusitis. The Health Plan denied the enrollees request indicating that the requested treatment 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 referral is not medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested an Anser ADA test for evaluation of her Crohn's disease. Findings: Three physician reviewers found that the use of Anser ADA has not been clinically proven to improve patient clinical outcomes, and has not definitively demonstrated clinical utility. Clinical guidelines for management of inflammatory bowel disease do not recommend testing for anti-drug antibody during clinical management. A review article reported that the available data do not allow final conclusions about the relevance of anti-adalimumab antibodies to the clinical efficacy of adalimumab, and another concluded that prospective controlled trials are direly needed to investigate the optimal tailored management in individual patients who lose response. Therefore, the medical literature does not support Anser ADA as likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: Three reviewers determined that the services at issue were 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: All three reviewers are board certified in internal medicine with sub-specialty in gastroenterology and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

A 49-year-old male enrollee requested authorization and coverage of a Glucowatch. The Health Plan denied the request indicating that the requested equipment is considered investigational for treatment of the enrollees diabetes mellitus. Three physician reviewers performed an experimental/investigational Independent Medical Review. Two of the three physician reviewers concluded that the requested equipment is likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy. One of the three physician reviewers concluded that the requested equipment is not likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy. Because two of the three physician reviewers concluded that the requested equipment is likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy, the Health Plans denial has been overturned.
Appeal type: Medical Necessity
Decision: Upheld

A 73-year-old female enrollee has requested magnetic resonance imaging (MRI) of the brain for evaluation of her left sided headaches.  Findings:  The physician reviewer found that based on review of the available records, this patient presented with a chronic unchanging headache. The CT  showed no evidence of sinus disease or any pathology and was reassuring such that no further imaging was indicated. According to the American College of Radiology (ACR) appropriateness criteria, the MRI imaging done on the date in question was not indicated as the patients condition was described as chronic, unchanging and there was no sudden onset, clinical evidence of neurological deficit, or suspicion of infection. As the CT scan of the said date was negative and the MRI was not expected to provide any novel information with regard to this patients diagnosis, the diagnostic procedure at issue has not been established as medically necessary in this clinical setting.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 50-year-old female with poor sleep, fatigue, and weight gain. Her representatives believe she has adult growth hormone deficiency (AGHD) based on a minimally normal increase in growth hormone response to arginine, a low IGF-1 on a single test, and the above listed clinical symptoms. All other general and metabolic blood tests as well as a bone density study are normal. The patient has requested authorization for growth hormone therapy. The Health Plan has denied this request. There is no evidence this patient has AGHD. The patients symptoms are non-specific. The results of her arginine stimulation test by themselves are not adequate to make a diagnosis of AGHD. In addition, a single low IGF-1 is not adequate to make a diagnosis of AGHD  particularly when all other pituitary parameters are normal. Therefore, there is no evidence to support a diagnosis of AGHD in this patient.Based upon the information set forth above, I have determined the requested therapy is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting authorization and coverage for the medication progesterone, 200 mg tablets, 90-day supply. The enrollee has been diagnosed with menopause. Medical records show she has been on progesterone, 100mg, and had breakthrough bleeding. The enrollee also reports she had an endometrial biopsy that was negative for cancer. She discussed hormone replacement therapy with her gynecologist, and received information about the risks of increasing the dose of her progesterone medication. The physician ordered progesterone, 200mg, for her condition. Based on the information received, it appears that the enrollee is having bleeding because of too much progesterone, and increasing the dosage will cause even more bleeding. Her bleeding may likely be due to progesterone breakthrough bleeding; i.e., it occurs when the ratio of progesterone to estrogen ratio is high. Increasing progesterone may likely increase bleeding.Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in obstetrics and gynecology and reproductive endocrinology 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.