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

Nature of Statutory Criteria/Case Summary:  The parent of an enrollee has requested 12 hours of direct applied behavioral analysis (ABA) therapy per week, 5 hours per week of assessment, and 5 hours per week of treatment planning for treatment of the enrollees autism spectrum disorder.  Three physician reviewers found that according to Myers and Johnson, Children who receive early intensive behavioral treatment have been shown to make substantial, sustained gains in IQ, language, academic performance, and adaptive behavior as well as some measures of social behavior, and their outcomes have been significantly better than those of children in control groups. In this case, the Health Plan states that a reduction in hours is clinically justified to be in line with having a 40 hour per week program. However, the documentation submitted does not show that he receives interventions at school. Therefore, ABA is medically necessary and should be provided for this patient at a minimum of 12 hours per week with 5 hours per week of assessment, and 5 hours per week of treatment planning.  Final Result: Three reviewers 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: One reviewer is board certified in child neurology and is actively practicing. One reviewer is board certified in pediatrics with sub-specialty certification in developmental-behavioral pediatrics and is actively practicing.  One reviewer is board certified in neurology with special competence in child neurology 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: Experimental/Investigational
Decision: Upheld

A 54-year-old male enrollee has requested mechanized spinal distraction therapy for spinal decompression for treatment of his neck and right arm pain.  Findings:  Three physician reviewers found that vertebral axial decompression for the cervical or lumbar spine is an unproven treatment modality.  High-grade peer-reviewed medical literature supporting the efficacy of vertebral axial decompression in the management of cervicalgia with or without radicular symptoms has not been published.  The manual or mechanical distraction of vertebral bodies and facet joints to reduce pain from nerve irritation has been shown in some smaller studies to be possibly effective for radicular neck pain.  The quality of evidence in support of this, however, is not strong.  The small case series that do demonstrate efficacy of cervical distraction suggest that over-the-door cervical traction devices can be effective.  There is a lack of high-grade published peer-reviewed data to support improved marginal functional outcomes for the device used in this case over home over-the-door cervical traction models for cervicalgia with or without radicular symptoms.  All told, the mechanized spinal distraction therapy for spinal decompression provided during the dates in question was not likely to be more efficacious than other treatment options.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Pazeo drops 0.7% 2.5 ml in 4 ml bottle. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication in this clinical setting. Olopatadine is a standard treatment for allergic conjunctivitis. It is both an antihistamine and also a mast cell stabilizer. It comes in three different concentrations: 0.1%, 0.2% and 0.7%. This patient was first prescribed a different drop, ketotifen, which was not effective. Next, he was prescribed the highest concentration of olopatadine (0.7%). However, there is no documentation that he has tried any other drops or that he had tried and failed the lower concentration olopatadine (0.1%) as a first step. As such, the documentation does not support using the higher concentration of olopatadine over the lower concentration of the medication. Therefore, Pazeo drops 0.7% 2.5 ml in 4 ml bottle is not medically necessary for the treatment of this patients eye condition. Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients eye condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in ophthalmology 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 physical therapy. This patient with cervical radiculopathy has experienced persistent neck pain and other symptoms including headaches and dizziness. She reported some symptomatic improvement and range of motion improvement with formal physical therapy. There is a paucity of high-quality evidence informing treatment for cervical radiculopathy, including the efficacy of exercise and physical therapy interventions such as manual therapy and traction. Current treatment guidelines related to the management of cervical radiculopathy are lacking, while higher quality studies are underway. There is a lack of high grade, evidence-based support for prolonged formal physical therapy in this clinical setting. Treatment should include services in the formal therapy setting until transition to an independent program can be made. However, there is a lack of an indication in the available records that this patient has impairments that preclude full transition to an independent program with exercises and modalities that can be applied independently for further improvement in range of motion and symptomatic management. There is no reasonable expectation that her clinical course or outcomes with further formal therapy would be marginally improved over an independent program. The patients documented exercises in the formal therapy setting can be performed independently or substituted with independent exercise. For palliation, the patient can use topical heat, self-massage techniques, and independently applied electrical stimulation pads. All told, the requested physical therapy is 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 physical medicine and rehabilitation 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 female enrollee requested Copaxone 40 mg/mL syringe subcutaneous for medical treatment of her multiple sclerosis.  Findings:  The physician reviewer found that the requested regimen consisting of Copaxone 40 mg has been shown to be effective in clinical trials and the data is nearly identical to the findings supporting dosing at 20 mg. As this patient has a relapsing form of multiple sclerosis, a disease-modifying agent is medically necessary. In addition, the patient has documented injection site reactions that warrant fewer injections per month. All told, the requested Copaxone 40 mg syringe subcutaneous three times weekly is medically necessary for treatment of this patients multiple sclerosis.
Appeal type: Medical Necessity
Decision: Upheld

A 41-year-old female enrollee has requested physical therapy for treatment of her severe right shoulder injury and right hand crush injury in a motor vehicle accident.  Findings:  The physician reviewer found that the patient sustained multiple injuries involving her right upper limb, particularly the hand and digits.  She sustained open soft tissue, tendinous, bony and vascular injuries.  These types of injuries, particularly when affecting the proximal digits, are often complicated by residual pain, stiffness, and dysfunction.  Keys to therapy revolve around early intervention with prolonged, low-load stress to restore and maintain range of motion.  In this patients case, she has undergone extensive hand therapy following her injuries a few years ago.  Despite therapy, she has persistent significant stiffness and dysfunction, particularly at the distal right upper limb.  There is persistent atrophy.  In this case, a significant, sustained benefit with respect to outcomes (e.g., hand function) is not expected with more formal therapy over an independent program.  The patient has had a sufficient number of therapy visits to be able to continue an exercise and modality program independently.  All told, the requested physical therapy is not medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for digital breast tomosynthesis. 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 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.  In this particular patient, the patients breast tissue has been described as being dense. While her mammogram has not changed since the last study, it is specifically those patients who have dense breasts that can benefit most from digital breast tomosynthesis. The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor. Final Result: Three reviewers determined that the service 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: All three 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: Experimental/Investigational
Decision: Overturned

A 75-year-old male enrollee has requested for pulmonary vein ablation for treatment of his atrial fibrillation. Findings:  Three physician reviewers found that pulmonary vein ablation has become an accepted tool for the management of refractory, symptomatic atrial fibrillation. While long-term efficacy data is still evolving, clinical practice supports its use in symptomatic patients that have failed traditional medical therapy. Alternative treatments such as Rythmol, sotalol, flecainide and amiodarone and cardioversion have already been tried without success.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary:An enrollee has requested authorization and coverage for Radicava.Findings:  The physician reviewer found that there is limited peer reviewed studies demonstrating the efficacy of the proposed treatment in patients with ALS.  Double blinded placebo controlled trials of Radicava in ALS have not demonstrated a change of motor scores relative to strength compared to placebo.  There is only one study demonstrating efficacy of the proposed treatment in a small subgroup of patients with ALS.  At this time, the efficacy of Radicava has not been well established. All told, Radicava is not likely to be more effective than the other methods of treating this patients medical condition Final Result: Two of the three he reviewers determined that the requested medication is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewers are  board certified in neurology 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

A 45-year-old female enrollee has requested transcranial magnetic stimulation (TMS) therapy for treatment of her major depressive disorder.  Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested services.  There is adequate support in the peer-reviewed literature for transcranial magnetic stimulation in this clinical setting.  The American Psychiatric Association has endorsed transcranial magnetic stimulation for the treatment of individuals with depression.  In this particular case, the patient is enduring an acute major depressive episode that is causing significant morbidity and functional impairment.  She has pursued other standard therapies used to combat depression.  Considering the medical records, endorsement from the American Psychiatric Association and the expanding peer-reviewed literature base, transcranial magnetic stimulation is an appropriate treatment.  All told, TMS therapy is medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

A 20-year-old female enrollee has requested for acute inpatient level of care for treatment of her behavioral health issues.  Findings:  The physician reviewer found that while the efficacy of acute inpatient treatment for treatment of eating disorders is well established, the evidence regarding the appropriateness of residential level of care for treatment of such patients is less convincing. An article by Frisch, et al. noted that future research is needed to focus on quantifying treatment program effectiveness in the residential treatment of individuals with eating disorders. In the case of this patient, she engaged in many negative behaviors including substance abuse and a lack of overall cooperation during her RTC stay. Moreover, this patient has no previous intensive outpatient program (IOP) or partial day hospital (PDH) treatment history. It is documented on numerous occasions that she needed structure in order to function adequately, however, there are no documented failures at lower levels of care.
Appeal type: Experimental/Investigational
Decision: Upheld

A 41-year-old female enrollee has requested for a positional MRI for evaluation of her back pain. Findings:  Three physician reviewers found that there is no peer-reviewed literature supporting the use of positional MRI over conventional MRI for low back pain. Positional MRI produces motion artifacts resulting in image irregularity. The diagnostic procedure at issue remains investigational in nature at this time and there is no evidence its use results in improved clinical outcomes.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollees parent has requested authorization and coverage for sublingual immunotherapy and/or food tolerance induction. This patient presents with a history of food allergies and dermatitis due to ingested food. The patients provider has recommended treatment with oral immunotherapy. Currently, the American Academy of Allergy, Asthma, and Immunology (AAAAI) does not recommend oral immunotherapy as a standard of care treatment for patients with food allergies due to uncertainty whether the potential therapeutic benefits outweigh the risks of treatment. Although several studies have reported positive outcomes, according to the AAAAI, the interventions and endpoints used in clinical trials are too inconsistent to establish oral immunotherapy as superior to allergen avoidance. Furthermore, there is significant potential for adverse events including oropharyngeal, respiratory, and gastrointestinal symptoms. Therefore, the requested sublingual immunotherapy and/or food tolerance induction is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Findings:  Three of the three physician reviewers found the requested sublingual immunotherapy and/or food tolerance induction is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewer 1 is board certified in internal medicine with subspecialty certification in allergy and immunology and is actively practicing. Physician reviewer 2 is board certified in internal medicine with subspecialty certification in allergy and immunology and is actively practicing. Physician reviewer 3 is board certified in allergy and immunology with subspecialty certification in pediatrics 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

Nature of Statutory Criteria/Case Summary:   An enrollee has requested residential treatment program services for treatment of his behavioral health condition.   Findings: The physician reviewer found that the submitted documentation fails to establish the medical necessity of the services at issue. At the time of admission, the patient was not in active withdrawals and his symptoms were mild at best. He was medically and psychiatrically stable. He was not cognitively or physically impaired. Moreover, his medication management did not require residential level of care. He demonstrated motivation and was an active participant. Although his sober support system was not a strong one and he was at risk for relapse, this in and of itself is not a reason to keep a patient at a higher level of care in the absence of  unstable psychiatric illness or the potential for harm to self or others. In sum, the patients treatment could have been provided at a lower level of care along with community support such as a 12-step group with a sponsor. Thus, the patient does not require 24 hour supervision at the residential level of care.  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 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 45-year-old female enrollee has requested laser treatment (Excimer ultraviolet laser) including CPT codes 96920 x 28 units, 96921 x 1 unit and 96922 x 1 unit for treatment of her medical condition.  Findings:  Two physician reviewers found that although the patient has undergone some first-line therapies without success, she has not yet tried and failed treatment with other first-line agents, including PUVA (psoralen in conjunction with UVA phototherapy) or methotrexate (Poligone, et al., Vonderheid, et al. and Christensen, et al.). The submitted documentation includes no indication of contraindications to these treatments in this patient. While lymphomatoid papulosis (LyP) is a rare disease and the patients assertion that studies of new treatment modalities will be slow to emerge is likely true, she has not failed the current standard first-line therapies that years of experience have shown to be effective. There is some evidence that Excimer laser may be effective for treatment of LyP; however, the current evidence is not substantial enough to recommend this modality as treatment for this condition (Poligone, et al.). Given the availability of standard treatments that have yet to be tried by this patient, there is insufficient evidence that Excimer laser treatment is likely to be of greater benefit than conventional treatments.
Appeal type: Experimental/Investigational
Decision: Overturned

The parents of a 16-year-old male enrollee requested authorization and coverage of bilateral hip arthroplasties. The Health Plan denied the request indicating that the requested procedure is considered investigational for treatment of the enrollees avascular necrosis of the hips.Three physician reviewers performed an experimental/investigational Independent Medical Review. All three physician reviewers concluded that the requested therapy is likely to be more beneficial for treatment of the enrollees medical condition than any available standard therapy. Because all three physician reviewers concluded that the requested therapy is likely to be more beneficial for treatment of the enrollees medical condition than any available standard therapy, the Health Plans denial has been overturned.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for right shoulder Euflexxa injections. The submitted documentation fails to demonstrate the medical necessity of the requested services. This patient presents with a history of persistent right shoulder pain. Clinical examination findings documented limited range of motion and weakness. There is reported imaging evidence of glenohumeral osteoarthritis. Corticosteroid injections to the right shoulder have failed to provide adequate relief of symptoms. Current medical guidelines do not support the use of hyaluronan injections for the treatment of shoulder conditions. There is a lack of large volume, long-term peer-reviewed outcome studies to support the use of hyaluronan injections in the treatment of glenohumeral osteoarthritis. There is no compelling rationale presented to support the medical necessity of Euflexxa injections for this patient. Therefore, right shoulder Euflexxa injections are not medically necessary for the 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 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.