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

Nature of Statutory Criteria/Case Summary: An enrollee has requested allergy testing for evaluation of her medical condition.  Findings: Three physician reviewers found that, although higher concentrations of food-specific antibodies correlate to an increased likelihood of a reaction upon ingestion, an individual patient with a significant food allergy can have a high, medium, low, or even negative in vitro test.  Additionally, a patient can have a low positive test for a food to which they are tolerant.  Thus, the patients clinical history is critical to both determining the tests to perform and confirming the diagnosis.  Large panels of testing rarely provide useful information and are not performed as the standard of care for the work-up of this patients symptoms.  Therefore, the services at issue were not likely to have been of greater benefit than other modalities.  Final Result: Three physician 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 certification 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: Medical Necessity
Decision: Overturned

The patient is a 40-year-old female with a history of migraines, worse with menstruation, for at least six years. In January 2005, the patients physician recommended an MRI of the brain due to an increase in the frequency of headaches. The MRI was unremarkable. The submitted status reports indicate that while the patient may have had a favorable response to various medications, it was only for a short duration. The patient started receiving acupuncture in February 2005. In addition, she changed her eating habits and began exercising regularly. The patient reports this regimen has helped reduce the frequency of her migraines and that she has lost weight and is generally feeling better with acupuncture treatment. The patient further indicates she has been able to reduce her medication dosage.  At issue is whether acupuncture is medically necessary for treatment of the patients medical condition.Because of the patients poor response to prescribed medications and her more favorable response to acupuncture treatment, continued acupuncture is more appropriate for treatment of the patients medical condition than pharmacotherapy. Since the patients symptoms appear to worsen during her menstrual period, one or two acupuncture treatments at that time are indicated for relief of migraines associated with her period. In addition, the patient should continue her exercise program and improved eating habits. Based upon the information set forth above, I have determined that the requested therapy is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

A 37-year-old male enrollee requested authorization and coverage of orthognathic surgery. The Health Plan denied the request indicating that the requested surgery is not medically necessary for treatment of the enrollees medical condition.One oral surgical reviewer performed a medical necessity Independent Medical Review. The oral surgical reviewer overturned the Health Plans denial on the basis that the requested services are medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 56-year-old female with a long history of depression and apparently other medical issues who was admitted to the hospital in March 2005. She was reported to be thinking of suicide without a plan. The patient has also been experiencing marital problems. It was noted the patient had occasional derogatory auditory hallucinations. She also has a long history of non-lethal self-mutilation. The patient has been treated with antipsychotic and antidepressant medications with positive results. She was admitted to a residential treatment program in March 2005 where it appears she remained until April 2005, except for a brief transfer to a hospital for medical attention. A request has been made for reimbursement for these inpatient psychiatric treatment services. The Health Plan has denied the request indicating the submitted documentation does not demonstrate inpatient psychiatric treatment services were medically necessary beyond April 2005.Based upon the information provided, there is no evidence to suggest the patient was actively suicidal or psychotic as of April 2005. The submitted documentation does not include any clinical records documenting the patients status as of April 2005. Thus, there is no evidence establishing the patient required continued inpatient psychiatric treatment as of that time. Therefore, I have determined that based upon the information provided, the services at issue were not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: enrollee has requested authorization and coverage for a monthly injection of Saxenda 3 mg. The submitted documentation fails to demonstrate the medical necessity of the requested medication. According to the U.S. Food and Drug Administration (FDA), Saxenda is approved as an adjunct to a reduced-calorie diet and increased physical activity for chronic weight management in adult patients with an initial body mass index of 30 kg/m2 or greater or 27 kg/m2 or greater in the presence of at least one weight-related comorbid condition, such as hypertension, type 2 diabetes mellitus or dyslipidemia. The initial management of individuals who would benefit from weight loss is a comprehensive lifestyle intervention, which includes a combination of diet, exercise and behavioral modification. All patients who would benefit from weight loss should receive counseling on diet, exercise and goals for weight loss. When a patient with a body mass index of 30 kg/m2 or greater or a body mass index of 27 to 29.9 kg/m2 with comorbidities has failed to achieve weight loss goals through diet and exercise alone, a pharmacologic therapy is suggested. However, the medical evidence has not demonstrated that Saxenda is more effective than the listed formulary drugs, diethylpropion or benzphetamine. Therefore, a monthly injection of Saxenda 3 mg is not medically necessary for the treatment of this patient. 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 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 authorization and coverage for lymphovenous anastomosis (LVA) procedure to the an upper extremity. The records provided for review document that this patient developed lymphedema after initial lumpectomy, chemotherapy, re-excision and completion lymphadenectomy with radiation therapy.  The provider noted that the patients progressive symptoms resulted in an episode of severe cellulitis, which required inpatient hospitalization and prolonged antibiotics. This patient meets the accepted indications for surgical management of secondary lymphedema. The patient failed nonoperative management with compression garments, manual lymphatic drainage, and daily use of an intermittent pneumatic compression device. They experienced recurrent episodes of cellulitis, the worst of which required inpatient hospitalization and prolonged antibiotics. Based on the current medical evidence, the requested LVA procedure to the upper extremity is 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 likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewer 1 is board certified in surgery with subspecialty certification in vascular surgery and is actively practicing. Physician reviewer 2 is board certified in surgery with subspecialty certification in vascular surgery and is actively practicing. Physician reviewer 3 is board certified in plastic surgery and is 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

A 46-year-old male has requested approval for past facet joint injections for treatment of his back pain.  Findings:  The physician reviewer found that on review of the patients records, the lumbar facet injections performed were not medically necessary for treatment of his medical condition. The patients history and physical examination from several office visits did not indicate whether the patients pain was derived from the facet joints. The imaging studies are significant for multi-level lumbar degenerative disc disease, facet hypertrophy, and neuroforaminal narrowing. It is difficult to determine the pathology of the patients chronic pain based on a physical examination without mention of findings on facet loading and imaging studies. In addition, the medical literature shows evidence for diagnostic lumbar facet injections in treating facet syndrome. However, per medical records, the technique of the lumbar facet injections performed were therapeutic and not diagnostic. The diagnosis of facet joint pain is made by diagnostic facet joint or median nerve branch injections with a local anesthetic. Ackerman and colleagues noted that non-radicular pain may be difficult to accurately diagnose and treat. The authors conducted a randomized controlled trial to determine if the results of diagnostic facet joint injections are influenced by the technique used to perform these injections. The results suggested that local anesthetic injections are useful for diagnosis of non-radicular low back pain, but may yield false positive results with respect to lumbar facet pain depending on the technique utilized. Seghal and colleagues performed a two-year literature review to update current scientific evidence on the diagnostic utility of facet joint injections. The authors reported that diagnostic injections are used to diagnose facet joint pain because available techniques cannot identify the pain generators in patients with chronic spinal pain. Facet joint injections are used to determine if pain is arising from these joints, distinguish painful from non-painful joints, and gauge a patients response to therapeutic facet joint interventions. The evidence suggests that comparative local anesthetic blocks of facet joints are reproducible, reasonably accurate, and safe.
Appeal type: Medical Necessity
Decision: Upheld

A 54-year-old female enrollee has requested computer-assisted hip replacement surgery for treatment of her osteoarthritis. Findings:  The physician reviewer found that although this patient meets the criteria for total hip replacement based upon the records reviewed, computed-assistance hip replacement surgery for this patients hip condition is not supported as medically necessary. Total hip arthroplasty is a successful procedure when nonsurgical management has failed for patients with symptomatic hip osteoarthritis. Reininga and colleagues conducted a review of the literature which demonstrated the safety of computer navigated total hip arthroplasty in terms of operative time, blood loss, and component malposition as well as complication rates. However, the authors concluded that the beneficial effect on functional recovery has yet to be proven. All told, total hip arthroplasty is an accepted technique which has high functional outcomes at long-term follow-up, thus use of computer assistance is not indicated. For these reasons, computer-assisted hip replacement surgery is not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for infliximab (Inflectra), dosed at 22 mg/kg given every two weeks for two to four treatments. Assa and colleagues note that it is common for patients with very early onset inflammatory bowel disease (VEO-IBD) to require higher than standard doses of infliximab. Bramuzzo and colleagues report that while there are very few data regarding the use of infliximab in children with VEO-IBD, compared with older children, VEO-IBD patients have higher rates of infliximab failures, lower remission rates at one year, and more often experience adverse events during induction.  In this case, the patient has VEO-IBD that has not responded to steroids, enteral nutrition therapy, or vedolizumab.  He has received multiple infusions of infliximab, at an escalated dose and frequency, showing slight symptomatic improvement for roughly one week after each dose. Infliximab trough levels checked at the four week point were sub-therapeutic, in the 3 to 4 mcg/mL range, whereas a level of 10 to 12 would be more appropriate. The patients temporary and incomplete symptomatic improvement after infliximab treatment may be indicative of a response, which he is unable to sustain due to either rapid metabolism or rapid clearance. Knowledge of whether this patient has true primary non-response to infliximab will be important for ongoing selection of medications as in the setting of primary non-response, further trials of anti-tumor necrosis factor (TNF) medications are likely to prolong treatment without any benefit and may simply delay the process of choosing other agents or proceeding to surgery, whereas if there is response to high-dose infliximab, the patient may be able to decrease his dose after intestinal inflammation decreases and drug loss through the intestinal wall is slowed as opposed to transitioning to a different anti-TNF agent. In this clinical setting, given the lack of multiple treatment alternatives, the short-term trial of frequent high doses of infliximab is medically indicated for the treatment of this patients persistent, moderate-to-severely symptomatic VEO-IBD. Therefore, infliximab (Inflectra), dosed at 22 mg/kg given every two weeks for two to four treatments is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested medication regimen 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 with sub-specialty certification in pediatric 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: Experimental/Investigational
Decision: Upheld

A forty year-old male with a history of coronary artery disease is requesting authorization of a CT angiography.  Reviewers Findings:The three reviewing physicians found that CT coronary angiography is a rapidly developing technology for visualization of the coronary arteries, but is still not considered the standard of care for evaluation of coronary disease.  The reviewing physicians found that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for proton beam radiation therapy (CPT-77370). Findings:  The physician reviewer found that According to Baxi and colleagues, the use of proton beam radiation therapy in head and neck cancer can provide for more conformal radiotherapy compared to standard treatment with photons and may reduce the dose to critical organs at risk. Some reports, however, suggest that patients may have worse toxicities, include dermatitis, neurologic toxicity and temporal lobe necrosis. Currently, there is a lack of clinical data to support the routine use of proton beam radiation therapy in head and neck cancers. Furthermore, there is a lack of  published randomized trials that support the use of proton beam radiation therapy over standard treatment with photons. Trials are currently ongoing to determine if patients who receive proton radiation therapy have improved local control and reduced side effects compared to patients who receive treatment with photons. Additionally, the current National Comprehensive Cancer Network guidelines also do not support the routine use of proton therapy in treatment of head and neck cancer. Therefore, proton beam radiation therapy (CPT-77370) is not 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 radiation 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: Overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement and prospective authorization and coverage for 40 hours per week of one-on-one applied behavioral analysis (ABA) therapy, two hours per week of caregiver training, 16 hours per week of program supervision by Board Certified Behavior Analyst (BCBA) and eight hours per month to conduct clinical team meetings for treatment of the autism.  Findings:  The physician reviewer found that Linstead and colleagues studied the intensity and learning outcomes in the treatment of children with autism spectrum disorder. The study showed a strong relationship between treatment intensity and mastery of learning objectives, where higher treatment intensity predicted greater progress. The Behavior Analyst Certification Board indicates that typical comprehensive ABA programs range from 30 to 40 hours of treatment per week. In this case, given the patients behaviors that include elopement, self-injury, aggression, noncompliance and tantrums, stereotypy, protests, and verbal and physical self-stimulatory behaviors, the request for 40 hours per week of one-on-one ABA therapy, two hours per week of caregiver training, 16 hours per week of program supervision by BCBA and eight hours per month to conduct clinical team meetings was and is medically necessary for treatment of the patients autism spectrum disorder. Final Result: The reviewer determined that the services at issue were and 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 pediatrics with sub-specialty certification in developmental-behavioral 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary:An enrollee has requested reimbursement for the water circulating cold pad with pump for treatment of the enrollees medical condition status post knee surgery. Findings:  Two physician reviewers found that the water circulating cold pad with pump provided was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The use of icepacks is the standard of care in this clinical setting. A researcher performed a meta-analysis on the use of cryotherapy following anterior cruciate ligament reconstruction. Six studies were reviewed. Some individual studies reported significant benefit. However, pooled analysis did not support a significant impact compared to traditional methods of delivering cold, such as icepacks. A study provide support for reduction in pain levels at 48 hours but does not provide sufficient evidence for efficacy of cryotherapy for other outcomes such as analgesic medication use, range of motion, blood loss, hospital stay or quality of life. The authors concluded that there was a need for additional studies with randomized trials before the ambiguity as to the efficacy of cryotherapy can be resolved. In summary, while cold therapy may be beneficial, there is a lack of sufficient support in the peer-reviewed literature for its use in this clinical setting. Final Result: The reviewers determined that the equipment at issue was 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: Reviewers 1, 2 and 3 are board certified in orthopedic surgery 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.