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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for artificial intervertebral disc. Findings:  Three physician reviewers found that this patient presents with progressively worsening neck pain radiating into the bilateral upper extremities, with numbness, tingling and weakness. The enrollee's pain was reportedly constant and interfered with activities of daily living. Clinical examination documented positive Spurlings test consistent with imaging evidence of severe spinal stenosis at the C4-5, C5-6, and C6-7 levels. The enrollee also had symptoms consistent with electrodiagnostic evidence of bilateral ulnar neuropathy, left greater than right, and bilateral carpal tunnel syndrome. The enrollees provider recommended hybrid surgery with cervical total disc replacement at C4-5 and C5-6 and anterior cervical discectomy and fusion at C6-7. The current medical literature suggests that hybrid surgery may be an effective alternative to multilevel fusion for cervical spondylosis. However, studies with larger sample sizes and longer follow-up periods have been recommended to provide further evidence. There is a lack of large volume, long-term, peer-reviewed outcome studies to support the use of these procedures for this patient. Therefore, the requested artificial intervertebral disc is not likely to be more effective than other treatment options. 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 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.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 17-year-old female has requested an insulin pump for treatment of type 1 diabetes mellitus.    Findings:  The physician reviewer found that the patient is likely escaping from her relative remission period. She is thus an excellent candidate for an insulin pump. The requested insulin pump is medically appropriate and should be authorized. Adequate evidence has been provided to support the use of an insulin pump in this setting.
Appeal type: Medical Necessity
Decision: Upheld

A 43-year-old male enrollee has requested OxyContin for treatment of his chronic low back pain.   Findings:  The physician reviewer found that review of the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested medication. The patients chief complaint is multi-joint pain including back pain and the patients symptoms do not necessitate OxyContin or any other opioids. The current standard of care for chronic pain is treatment in a multidisciplinary practice to include physical therapy, massage therapy, cognitive behavioral therapy, and injections to help reduce pain. Opiates are considered adjunctive to this therapy and at that point opioids should be prescribed with close monitoring by a certified pain management physician. Thus, the request for OxyContin would be contradictory to providing safe and effective treatment. Based on the documentation submitted for review and the peer-reviewed literature cited above, the requested medication is not medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested breast tomosynthesis for 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.  While one could make the argument that her mammogram has not changed since the last study, it is specifically those patients who have dense breasts that can benefit most from tomosynthesis.  The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor.  Thus, breast tomosynthesis was likely to have been more effective than other methods for evaluating this patient. 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: Overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement and prospective authorization and coverage for 172 hours per month of one-on-one applied behavioral analysis (ABA) therapy, 17 hours per month of supervision and six hours per month of parent training. Findings:  The physician reviewer found that The Health Plan has authorized 35 hours per week of direct ABA therapy, 15 hours per month of supervision and six hours per month of caregiver training. The Behavior Analyst Certification Board states that typical comprehensive ABA programs range from 30-40 hours of treatment per week. In this case, the patient has made progress in many areas as evidenced by the progress report, but he continues to demonstrate impairment in several areas including aggression, self-injury, tantrums, property destruction and non-compliance. The patient has failed to respond adequately to medications, increasing the likelihood of outburst behaviors and regression with decreased ABA hours. Based on the documentation submitted for review, the request for 172 hours per month (40 hours per week) of one-on-one ABA therapy, 17 hours per month of supervision and six hours per month of parent training were and are medically necessary for treatment of the patients medical condition.Final Result: The 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: Physician 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: Medical Necessity
Decision: Overturned

The patient is a 24-year-old female with a body mass index (BMI) of 53. Previous attempts at medically supervised weight loss were unsuccessful. The patient has multiple obesity related comorbidities. She has obtained psychiatric clearance and wishes to undergo gastric bypass surgery. The Health Plan has denied authorization for gastric bypass surgery on the basis that it is not medically necessary. With a BMI of 53 and comorbid conditions the patient meets nationally accepted medical necessity criteria for consideration of weight loss surgery. It is highly likely that gastric bypass surgery will be beneficial for this patient. Furthermore, the patient does not require further dietary workup prior to undergoing weight loss surgery. There is no clinical evidence demonstrating that further weight loss is necessary for a successful surgery and there is no scientific evidence supporting this requirement. Therefore, I have determined the requested procedure 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 a VistaSeq Hereditary Cancer Panel for evaluation of her medical condition.  Findings:  Two physician reviewers found that there is sufficient support for the requested services in this clinical setting.  This patient had had two cancers at a young age and has family members with several types of cancers, making her at significant risk of a hereditary cancer.  Testing would affect how she is screened and treated for risk of additional cancers and also if her family members need to be tested to decrease their risk. Given her ethnicity and variety of cancers, panel testing is recommended over standard testing with only BRCA1 and BRCA2.  In sum, the requested VistaSeq Hereditary Cancer Panel is likely to be more effective than other methods of evaluating this patient. Final Result: Two reviewers determined that the requested services are 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 internal medicine with sub-specialty certification in medical oncology 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: Upheld

A 49-year-old male enrollee has requested radiofrequency nerve ablation for the treatment of his back pain. Findings:  Three physician reviewers found that the requested treatment, radiofrequency ablation to the thoracic spine, is not likely to be more beneficial for this patients clinical situation than any available standard therapy and is not supported by the scientific literature. The literature notes that data regarding the efficacy of this procedure in the thoracic spine remains unproven. A systematic review by Boswell concludes, The evidence for pain relief with radiofrequency neurotomy of cervical and lumbar medial branch nerves is moderate for short- and long-term pain relief, and indeterminate for thoracic facet neurotomy. In this case the patient stated that he received benefit from medial branch block which tended to localize the pain. However, the scientific literature indicates that the efficacy of localizing pain with injections followed by radiofrequency ablation for thoracic facet syndrome has not been established. As such, there is insufficient peer-reviewed evidence to support the requested treatment in this setting.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for gene panel testing.Findings:  Two of the three physician reviewers found that the current medical evidence supports the services at issue in this patients case. The American College of Obstetricians and Gynecologists (ACOG) recommends expanded carrier screening as an acceptable strategy for prenatal carrier screening. Screened conditions should be able to be diagnosed prenatally and have potential opportunities for antenatal intervention to improve perinatal outcomes, changes to delivery management to optimize newborn and infant outcomes, and parental education about special care needs after birth. Therefore, gene panel testing was likely to have been superior over other available methods of evaluating this patient. Final Result: The 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: Physician reviewer 1 is board certified in clinical genetics and genomics and is actively practicing. Physician reviewer 2 is board certified in obstetrics and gynecology and is actively practicing. Physician reviewer 3 is board certified in clinical biochemical genetics 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: Experimental/Investigational
Decision: Upheld

A female enrollee requested Botox injections for medical treatment of her jaw pain and headaches.  Findings:  Two physician reviewers found that this patient has been diagnosed with TMJ disorder and migraine headache. Treatment of chronic migraine with Botox injections is supported in the peer-reviewed literature. However, the record does not document the patient has chronic migraine headaches. In addition, there is a lack of adequate medical studies for the treatment of TMJ disorder with Botox injections. Moreover, there are numerous management strategies for the treatment of TMJ disorder, such as physical therapy, oral devices and intra-articular injection. In this case, prior treatments for the patients TMJ disorder are not provided in the documentation submitted. As such, the records do not substantiate that Botox injection to the masseters were and are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting authorization and coverage for subacute care services. The enrollee underwent a hematoma evacuation, due to a basal ganglia hemorrhage caused by MoyaMoya disease. The enrollee underwent a tracheostomy and percutaneous endoscopic gastrostomy tube placement due to brain injury.  The enrollee experienced respiratory failure and was weaned off the ventilator. The enrollee participated in occupational therapy, physical therapy, respiratory therapy, and speech-language therapy. Recent progress notes show no additional physical therapy interventions were provided. The family was to continue range of motion exercises.  Percutaneous endoscopic gastrostomy feedings had increased the enrollees weight and were well-tolerated.  The speech therapy goal of two hours per week speech therapy for communication, cognition and dysphagia could be performed in a non-subacute care setting.Final Result: The reviewer determined that the requested services are not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 42-year-old female enrollee has requested acupuncture services for the treatment of her endometriosis. Findings:  The physician reviewer found that the patient's primary complaints are chronic endometriosis/abdominal problems, fatigue and back pain.  She is requesting continuation of acupuncture treatment.  The patient has been receiving ongoing acupuncture treatment for her symptoms. On prior progress reports, the pain level, as reported on an analog scale of 0 to 10, was between 3 and 4. It appears that this patient has plateaued, as there has been no significant change/deviation in the level of pain. Accordingly, at this time, the Health Plans denial of authorization for continued acupuncture treatment should be upheld as continued treatment would appear to be maintenance in nature.  Should the patient have an acute/severe exacerbation of symptoms, then further treatment might be considered at that time.
Appeal type: Experimental/Investigational
Decision: Overturned

A 33-year-old female enrollee has requested Botox injections for treatment of her headaches. Findings:  Two physician reviewers found that although Botox is not a first-line therapy for chronic headaches, there is adequate literature supporting its use in refractory cases. This patient has failed multiple preventive first-line headache therapies. Despite treatment, she has had significant disability. Given the documented failure of multiple preventive medications, further attempts with such agents are not likely to be effective. Consideration of Botox therapy is a medically appropriate and reasonable option at this juncture. The literature provides sufficient justification for the use of Botox in this setting. Thus, in this patients case, Botox injections are likely to be more efficacious than any available standard treatment.
Appeal type: Urgent Care
Decision: Upheld

A 56-year-old male enrollee has requested for emergency services for treatment of his skin rash.  Findings:  The physician reviewer found that the patients symptoms did not meet prudent layperson criteria for emergency care. A prudent layperson with an average knowledge of medicine and a moderately itchy, swollen, rash gradually worsening over one years time, would not reasonably expect the absence of emergency care to jeopardize their health. Although this patients symptoms were significant and required evaluation on an urgent basis, this care could have been safely provided within the Health Plan and was not emergent.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for bone stimulator for nonunion right distal radius.  Findings:  The physician reviewer found that The submitted documentation supports the requested device in this clinical setting. The presence of a 4 to 5 mm gap indicates an established nonunion of the distal radius. Per the literature, in patients with an existing nonunion or delayed union, electrical stimulation had evidence of clinical benefit over standard care on union rates at three months. Some of the literature indicates healing in 12 months without bone graft. The external electrical stimulation is likely to be beneficial in this setting. Therefore, the requested bone stimulator for nonunion right distal radius is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested device 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 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 32-year-old female enrollee requested a transabdominal cerclage with an abdominal approach for medical treatment of the enrollees incompetent cervix.   Findings:  The physician reviewer found that the records indicate the patient had a successful outcome in her last pregnancy with placement of a vaginal cerclage. Thus, she is a candidate for another vaginal cerclage in her next pregnancy. She does not meet the guidelines for placement of an abdominal cerclage since she has not failed a prior vaginal cerclage and does not have cervical anatomic issues that precludes vaginal placement. All told, the requested transabdominal cerclage with an abdominal approach is not supported as medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The patient has requested authorization and coverage for Euflexxa injections in both knees. The patient has been diagnosed with bilateral knee osteoarthritis. Review of the current medical literature pertaining to viscosupplementation reveals mixed results. Although viscosupplementation may relieve knee pain in some patients with osteoarthritis, it is unknown which patients will benefit. Considering the foregoing, viscosupplementation can only be recommended for patients with a history of lasting benefit from prior injections and in carefully selected cases when everything else has been tried and the options are limited. In this case, the patient has a history of lasting benefit from prior viscosupplementation injections. Furthermore, the patients options are limited. Corticosteroid injections only provided temporary benefit. The patient has tried and failed other conservative treatments, with the alternative being a total knee arthroplasty. The medical evidence supports the requested services in this clinical setting. Therefore, Euflexxa injections in both knees are medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in 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

The patient is a 41-year-old woman with acne vulgaris. She had a chemical peel performed by a dermatologist with beneficial results. Treatment with doycycline, topical Retin-A micro gel, and sulfacetamide lotion was not effective. The patient and her dermatologist have requested reimbursement for the chemical peel procedure. The Health Plan indicates chemical peels are a cosmetic procedure, and therefore, has denied the request for reimbursement.The Health Plans denial should be upheld. Chemical peels are not medically necessary for the treatment of acne vulgaris. There are other treatment modalities, which were likely to be effective in this case including oral erythromycin, oral ampicillin, oral sulfur, topical Cleocin, topical benzoyl peroxide, topical erythromycin, Tazovac cream, Finacea, topical Differin, and Benzaclin. There is no evidence the use of a chemical peel was medically warranted for this patient. Therefore, I have determined that the procedure at issue was not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

A 41-year-old male enrollee requested removal of excess breast tissue for medical treatment of his gynecomastia. Findings:  The physician reviewer found that per the current medical evidence, surgical treatment of gynecomastia should be reserved for severe and refractory cases.  As noted by Pruthi and Jones, nonsurgical interventions and medical therapies should be considered as initial therapy.  In this case, the clinical documentation submitted for review fails to demonstrate that this patients condition is severe and refractory to nonsurgical treatment.  All told, the requested removal of excess breast tissue is not medically indicated for the treatment of this patient