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

This patient is a seven-year-old male with the diagnosis of autism who has received speech therapy since 2001. He has more recently been receiving speech therapy in conjunction with a behaviorist. The speech therapist has provided documentation from 2003-2005 regarding the patients progress. At issue is whether continued speech therapy is medically necessary.In reviewing the speech therapy progress reports and comparing goals and progress from 2003 to 2005 it is clear the patient is making progress in his speech and communication skills. Appropriate communication and social interaction is the first long-term goal and the patient has progressed from an inconsistent eye gaze with little to no verbalization and a vocabulary of less than 50 words to taking turns with up to 6 social exchanges. With regard to the second long-term goal of improved expressive language skills, the patient has gone from single-word gestures using only nouns to spontaneous two word semantic combinations. In the third long-term goal of improved receptive language skills, the patient has advanced from naming body parts to answering where questions.  These are real functional and speech related gains.It is important to note that in most therapy situations progress toward goals is viewed over weeks to months. Slower progress, over six months to a year for some skills, should be expected with autism, as is not just a speech disorder, but a behavioral disorder as well. The gains noted in this case are real gains and will have a significant impact on the patients ability to communicate in school, at home, and in the community.  Therefore, I have determined the requested therapy is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for radiofrequency neurolysis/ablation. Review of the literature with comprehensive analysis of the published data pertaining to the effectiveness and risks of fluoroscopically guided cervical medial branch thermal radiofrequency neurotomy for treating chronic neck pain of zygoapophyseal joint origin. The authors concluded that if performed as described in the International Spine Intervention Society guidelines, fluoroscopically guided cervical medial branch thermal radiofrequency neurotomy is effective for cervical zygoapophyseal joint pain and carries only minor risks. This patient complains primarily of severe left-sided neck pain with radiation to the shoulders and head. The provider does not document any evidence of radiculopathy. Based on the guidelines, the patient is a good candidate for radiofrequency neurotomy. For these reasons, the radiofrequency neurolysis/ablation performed and prospective authorization and coverage for radiofrequency neurolysis/ablation were and are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: Two of the three reviewers determined that the services at issue were and 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:  One reviewer is board certified in orthopedic surgery and is actively practicing. One Reviewer is board certified in orthopedic surgery and is actively practicing.  One Reviewer is board certified in orthopedic surgery 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: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for an increase of testosterone gel 1.62% to six pumps a day. Male hypogonadism may lead to reduced sexual desire, decreased spontaneous erections, loss of axillary and pubic hair, declining testicular volume, hot flashes, low or zero sperm count. Other less suggestive symptoms include depressed mood, poor concentration, increased body fat, decreased physical performance, reduced muscle mass. Thirumalai and colleagues report that there are a number of testosterone formulations currently available for the treatment of hypogonadism, including intramuscular and transdermal preparations, and several additional formulations under development. Values outside of a mid-normal range of serum testosterone level, between 400 ng/dL to 700 ng/dL may require a dose adjustment. In this case, given that the patients testosterone level is subtherapeutic, the requested medication regimen is medically indicated. Therefore, an increase of testosterone gel 1.62% to six pumps a day 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 internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism 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: A enrollee has requested authorization and coverage for One Touch Blue Test Strips. Findings:  The physician reviewer found that based on the available documentation, there is no medical rationale for the One Touch System. The patient can download the Accucheck meter data as well if this helps him to comply with diet, medication adherence. However, there is a lack of documentation supporting the use of the One Touch as medically necessary for evaluation and treatment of this patients diabetes. Thus, the One Touch Blue Test Strips are not medically necessary for evaluation of this patients medical condition. Final Result: The reviewer determined that the requested supplies are not medically necessary for evaluation 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 endocrinology, diabetes and metabolism 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 dexamethasone injections. In this case, the patient has low back pain without radiation into the lower extremities. She has MRI findings of facet arthritis involving L3-4 to L5-S1 without significant spinal canal stenosis. The patients physical examination findings are notable for lumbar paraspinal tenderness and limited range of motion with lumbar extension. The provider has recommended bilateral lumbar medial branch blocks of L3-4 to L5-S1. There is no indication that these injections are for diagnostic purposes to evaluate the patient for a possible radiofrequency ablation procedure. The providers notes suggest that these injections are intended for therapeutic purposes. The randomized control trial by Cohen and colleagues concluded that, facet blocks are not therapeutic. The higher responder rates in the treatment groups suggest a hypothesis that facet blocks might provide prognostic value before radiofrequency ablation. The best evidence for the use of medial branch blocks is for diagnostic purposes leading to a radiofrequency ablation procedure. Therefore, the requested dexamethasone injections are not medically necessary for treatment of this patient. 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 anesthesiology with subspecialty certification in pain management 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 patient has requested authorization and coverage for hyaluronan (Orthovisc) injections in the left knee for treatment of the enrollees grade 4 patellofemoral arthritis. Findings:  The physician reviewer found that Review of the current medical literature indicates continuing support for viscosupplementation of the knees for osteoarthritis. In particular, patients who have benefited from prior injections are likely to respond in a similar positive fashion to the repeat series of injections. Bowman and colleagues reported findings that support viscosupplementation for pain relief as well as improving function in osteoarthritis of the knees with the objective being to delay the total knee arthroplasty. In light of the foregoing, the requested hyaluronan (Orthovisc) injections in the left knee are supported as medically necessary for treatment of this patients left knee osteoarthritis and anterior cruciate ligament disruption. Final Result: The reviewer determined that the requested service is 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 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 35-year-old female enrollee has requested transthoracic echocardiogram for evaluation of her medical condition.   Findings:  The physician reviewer found that review of the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested service. The medical records provided for review indicate that the patient is a 35-year-old female with apparent chest discomfort that is not documented or characterized in the submitted clinical records. The American College of Cardiology guidelines do not consider repeat echocardiography one year from a prior normal exam appropriate or indicated. The documentation submitted for review indicates a normal echocardiogram and cardiac catheterization approximately one year ago and includes a clinic note documenting a normal cardiovascular and respiratory exam. In this patients case, she had a recent normal echocardiogram with no documentation characterizing the patients symptoms of chest discomfort. Therefore, the documentation submitted for review does not support the requested transthoracic echocardiogram as it is not medically necessary or standard of care in this clinical setting.
Appeal type: Medical Necessity
Decision: Overturned

This patient is a 53-year-old female with a 20-year history of multiple sclerosis (MS) and significant neuromuscular symptoms. Additionally, the patient has MS related chronic pain syndrome. She is currently on Elavil, Zonegran, Neurontin and Lyrica to control her pain. The patient has been using samples of Lyrica for over two months and reports that she has gained control of her pain and has substantially reduced her Neurontin dosage.The patients request for authorization of Lyrica was denied by the Health Plan citing a lack of medical necessity.Lyrica is currently prescribed by neurologists for neuropathic pain conditions with a wide range of etiologies extending well beyond the indications of post-herpetic neuralgia and diabetic peripheral neuropathy. As with this patient, the response has generally been very good. In this case, Lyrica was tried after several other medications were ineffective and the medication has provided the patient with relief from her chronic pain syndrome. Therefore, I have determined the requested medication is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a 16-year-old male enrollee has requested vision therapy and a visual examination for treatment of his visual defects.   Findings:  The physician reviewer found that it is not uncommon to find children with myopia, in one of both of their eyes, who are wearing glasses that are under corrected by 1 to 2 diopters. The patient sees 20/40 in each eye and is not amblyopic. The cause of his decreased visual acuity is congenital nystagmus. The patient is also said to have mild developmental delay and learning disabilities. There is no scientific evidence to support the use of vision therapy for learning disabilities or for congenital nystagmus.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:   An enrollee has requested breast tomosynthesis for the evaluation of her medical condition. Findings: Three physician reviewers found that breast tomosynthesis is a technique that was developed several years ago as a problem solving adjunct to routine mammography.  Applying the same basic concept as computed tomography (CT) scanning, the logic is that by separating the various layers of breast tissue, one can better detect abnormalities.  This has been shown to be most useful in the evaluation of dense breasts.  As noted by researchers, breast tomosynthesis has the potential to change conventional mammographic screening and diagnostic imaging with possible improvements in cancer detection, decreased callbacks, and fewer false positive biopsies.  In sum, breast tomosynthesis was likely to have been more effective than other methods of evaluation. Final Result: Three 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.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for magnetic resonance imaging (MRI) of the brain stem, with and without dye. There is no evidence of neurological deficit on physical examination. In addition, the review of systems revealed no weakness. There was no description of head trauma related to the motor vehicle accident (MVA). There are no records indicating that the patient has been evaluated by neurology visit and there is no documentation of worsening symptoms. While MRI may be appropriate for evaluation of patients with symptoms of cervicogenic headaches to rule out intracranial etiology, the records do not support worsening symptoms or need for neurological imaging of the brain. In the absence of abnormal physical findings and progressive clinical abnormalities such as weakness on neurological examination, the requested MRI of the brain stem, with and without dye is not medically necessary for evaluation of this patients medical condition. Final Result: The reviewer determined that the requested services are not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in diagnostic radiology 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 requested cervical disc replacement (discectomy and arthroplasty) for medical treatment of her medical condition.  Findings:  Two physician reviewers found that in this case, the requested services are not likely to be more effective than other treatment options.  Cervical total disc replacement has been increasingly used as an alternative to fusion surgery in patients with pain or neurological symptoms in the cervical spine who did not respond to nonsurgical treatment.  Although the available data shows promising results, it is not currently considered to be the standard of care for the treatment of cervical degenerative disorders.  In this case, there is no indication that the patient has completed all conservative treatments prior to the request for surgical intervention.  Therefore, per the peer-reviewed literature, the requested cervical disc replacement (discectomy and arthroplasty) would not be more beneficial for treatment of the patients medical conditions than any other available standard therapy.  Final Result: Two 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: Reviewers 1, 2, and 3 are board certified in orthopedic surgery and is actively practicing. The reviewers are 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 residential treatment center services for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found that the submitted documentation demonstrates that the patient was not at risk of severe withdrawal. The patient experienced post-acute withdrawal syndrome which was mild to moderate. He was medically and psychiatrically stable. There were no emotional, behavioral, or cognitive barriers to treatment at a lower level of care. He was not a danger to self or others.  Thus, treatment in a setting with 24-hour supervision, in the absence of unstable psychiatric illness or the potential for harm to self or others, was not medically necessary.  The patient could have been treated at a lower level of care in an ambulatory or outpatient setting. 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 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 55-year-old female enrollee has requested for a CT of the coronary arteries for evaluation of her heart blood vessels.   Findings:  Three physician reviewers found that there is no documentation to indicate the patient has an uninterpretable ECG or is unable to exercise. In this circumstance, coronary CT angiography has not been shown to be more beneficial (or even as beneficial) as stress testing, if further evaluation of chest discomfort is thought to be necessary. Appropriateness criteria for coronary CT angiography have been published, endorsed by several national organizations, and do not recommend using the test in this setting.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting authorization and coverage for HP Acthar Gel 40 units, 2 times per week for 4 weeks, then titrate to 80 units, 2 times per week for 5 months. The enrollee has stage 4 chronic kidney disease. At an office visit, her provider indicated the amount of interstitial fibrosis and tubular atrophy was working against her success rate. The providers recommendation was for the enrollee to continue angiotensin II receptor blockers The pharmacist reports the enrollees condition has worsened; despite maximum evidence-based, non-immunosuppressive therapy. She is spilling a high level of protein in her urine; at a rate of 7.3 grams per day. Normal urinary protein is less than 150 milligrams per day. The enrollees kidney biopsy displayed immunoglobulin A nephropathy, with 50 percent global sclerosis and 40 percent interstitial fibrosis and tubular atrophy. A recent study did not support the use of Acthar gel for those with immunoglobulin A nephropathy, as the study size was limited to five participants; one of whom terminated due to the adverse side effect of weight gain. Studies provide stronger support for immunosuppressants, such as leflunomide, for treating immunoglobulin A nephropathy. Studies showed immunosuppressive therapy can significantly reduce proteinuria and end stage renal disease risk in enrollees with immunoglobulin A nephropathy. While meta-analysis are available to support immunosuppressant use for refractory immunoglobulin A nephropathy, the same level of high evidence for Acthar gel in the treatment of immunoglobulin A nephropathy was not available. Additionally, the article which supports the use of Acthar gel for treatment of immunoglobulin A nephropathy notes that Acthar gel is indicated after the individual has failed more than two prior immunosuppressive or cytotoxic therapies. Medical records do not show the enrollee has trialed immunosuppressive or cytotoxic therapies.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 nephrology and 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 similar medical condition.