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

Nature of Statutory Criteria/Case Summary: An enrollee has requested celiac plexus nerve block for treatment of the enrollees chronic abdominal pain. Findings: The physician reviewer found that there is sufficient support for the requested services in this clinical setting. Celiac disease can be a cause of abdominal pain (Mahadov, et al).  Celiac plexus block is an effective therapy for chronic abdominal pain due to a number of causes, as the plexus provides sensation information from the liver, pancreas, spleen, omentum, alimentary tract to the mid-transverse colon, adrenal glands, and kidney.  It can decrease the need for opioid medications, which have risks (Rana, et al; Fields, et al).  Celiac plexus block is a relatively safe method to control abdominal pain that is unresponsive to medical treatments in patients with benign disease (Soweid, et al).  As such, celiac plexus block has demonstrated efficacy in this case.  For these reasons, celiac plexus block is supported as medically necessary for the treatment of the patients chronic abdominal pain.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 internal medicine with sub-specialty certification in 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: Medical Necessity
Decision: Upheld

A 62-year-old female enrollee has requested continued acupuncture for medical treatment of her osteoarthritis. Findings:  The physician reviewer found that the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested therapy. According to the documentation submitted for review, acupuncture has provided the patient some temporary relief without any functional improvements documented in terms of activities of daily living (ADLs) improvement, medication intake reduction, or exam findings showing progress towards self-reliance. The peer review literature supports the use of acupuncture for hip osteoarthritis (Witt, et al; Linde, et al), but also indicates that extension of acupuncture care is medically necessary if functional gains are documented such as improvement in activities of daily living, reduction in work restrictions, or reduction in medication intake (Official Disability Guidelines Hip). Therefore, given the lack of evidence of significant quantifiable response to treatment obtained with previous acupuncture care, a request for additional acupuncture is not supported. In addition, the request for acupuncture is open-ended, without indicating frequency or duration and the peer review literature indicates that any condition treated should be monitored to adjust the care and evaluate the benefits obtained. Based on the reasons provided, continued acupuncture is not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

A 20-year-old female has requested past and future coverage for acute inpatient psychiatric care for treatment of her behavioral health issues.  Findings:  The physician reviewer found that based on review of the available records, this patient presents with a history of major depressive disorder, recurrent, severe and bulimia nervosa. The patient presented with symptoms of depression with suicidal ideation as noted in the psychiatrists notes starting at the date in question. For the dates in question beyond the original date, this patient continued to have suicidal ideation with a plan to drive her car over a hill or overdose. The provider described her mental state as very despondent. The patient was planning and dreaming of her own death. Utilizing the practice guidelines from the American Psychiatric Association (APA), this patient continues to be at imminent suicidal risk necessitating the medical care and supervision provided in the patients current facility. She meets the criteria for an acute inpatient hospitalization as she continues to show suicidal ideation and self-injurious behavior and therefore the services provided from the date at issue and forward have been demonstrated to be medically necessary for management of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Findings:  The physician reviewer found that : The patients parent has requested authorization and coverage for Palforzia including the initial dose escalation phase, up-dosing phase, and maintenance phases. This patient has a documented allergy to peanut. The patients provider has recommended treatment with Palforzia, which is a means of prevention of anaphylaxis upon accidental exposure to peanut. Oral immunotherapy as a treatment for food allergies has been demonstrated to be an efficacious method of food allergy treatment in order to prevent anaphylaxis in well-selected patients. Vickery and colleagues evaluated 551 patients with peanut allergy who received either active treatment or placebo in a food challenge. The authors found that the patients treated with oral immunotherapy were better able to tolerate ingestion of peanut protein, with lower symptom severity at the exit food challenge than patients who received placebo. The U.S. Food and Drug Administration (FDA) has approved Palforzia as oral immunotherapy indicated for the mitigation of allergic reactions, including anaphylaxis, that may occur with accidental exposure to peanut. Given these findings, the requested Palforzia including the initial dose escalation phase, up-dosing phase, and maintenance phases, is medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in internal medicine with subspecialty certification in allergy and immunology 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 parent of a 17-year-old male enrollee has requested substance abuse residential treatment center services for treatment of the enrollees polysubstance dependence. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the services at issue in this patients case.  The patient was unable to maintain sobriety in the outpatient setting despite intensive chemical dependency services.  His peer group and social interactions were not conducive to clean and sober living, and his drug use was dominating multiple functional domains.  Further compromising the patients clinical picture was the presence of comorbid affective and anxiety disorders.  This patient demonstrates enduring intrapsychic conflict, self-defeating coping strategies and a fragmented sense of self that manifest with drug use, defiance and ambivalence.  Given this patients substance use, continued affective dysregulation and impulsivity, treatment at a lower level of care is likely to be unsuccessful.  Treatment in the residential treatment setting is reasonably expected to improve his condition while preventing a more serious episode of illness.  All told, substance abuse residential treatment center services provided from the date indicated forward were and are medically necessary for treatment of the enrollees medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

A 52-year-old female enrollee has requested BRCA1 and BRCA2 testing for evaluation of her cancer risk. Findings:  Three physician reviewers found that women found to have a mutation of the BRCA1 and BRCA2 genes have a high risk of developing breast and/or ovarian cancer. These mutations are particularly seen in women who have been diagnosed with breast cancer and in patients with a family history of certain cancers.  For women who have not had cancer, there are a variety of guidelines for the use of BRCA1 and BRCA2 testing. In this patients case, per National Comprehensive Cancer Network guidelines, testing is recommended if there are two or more close relatives with breast and/or ovarian cancer and at least one close blood relative diagnosed with breast cancer under the age of 50.  Thus, the requested BRCA1 and BRCA2 testing is indicated and is likely to be superior over other methods of evaluation.
Appeal type: Medical Necessity
Decision: Upheld

A 52-year-old female has requested for revisional bariatric surgery consultation and surgery for treatment of her obesity. Findings:  The physician reviewer found that the patient has no documented recent dietary or behavioral evaluation specifically regarding bariatric revisional surgery.  Per the records, there were no overt complications of the prior procedure mandating removal.  Given the increased risk of complications and morbidity, a thorough multidisciplinary evaluation documenting understanding of these risks, as well as an evaluation indicating likelihood of compliance, should be documented.  The current medical evidence does not support the requested services in this patients case.  All told, the requested revisional bariatric surgery consultation and surgery are not medically indicated for the treatment of this patient.
Appeal type: Urgent Care
Decision: Upheld

A 43-year-old female enrollee has requested ambulance transport for the treatment of her ear pain. Findings:  The physician reviewer found that a prudent layperson with an average knowledge of medicine would not have sought ambulance transport for treatment of her ear pain. Although this patient was having severe pain for which she reasonably sought medical care, there is no evidence that she could not have been driven by taxi, taken public transportation or been driven by private vehicle to the hospital. The patient was not noted to be unsteady on her feet, confused, or having any of the usual types of medical conditions (chest pain, acute trauma, stroke, confusion) that a prudent layperson would reasonably expect to require ambulance transport. It appears the ambulance was utilized for transport only, and the patient did not require any of the expertise or emergency equipment available on the ambulance to ensure safe transport.
Appeal type: Experimental/Investigational
Decision: Overturned

An enrollee has requested reimbursement for genetic testing. Gene panels are currently within the standard of care in this patients clinical scenario. The records provided for review document that the patients family has a medical history of breast cancer and prostate cancer. The patient does not have a personal history of cancer. Medical literature notes that progress in next-generation sequencing (NGS) has enabled to identify huge number of genetic aberrations. Researchers also reported that based on sequencing results, patients are recommended to undergo targeted therapy or immunotherapy. The NGS technology offers an improvement in efficiency in comparison to sequential analysis. Given this support, the genetic testing was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. 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 reviewers 1, 2, and 3 are board certified in genetics 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

The enrollee requested authorization and coverage for bilateral insertion of Latera absorbable nasal implant stents. This enrollee has a septal deformity and nasal valve collapse. She returned to her otolaryngologist and reported she was still having difficulty breathing. She reported Breathe Right strips helped. The impression was nasal obstruction, secondary to septal deformity, turbinate hypertrophy, and nasal valve collapse. The enrollee wants to avoid surgery; therefore, the otolaryngologists recommendation was for placement of Latera stents in the otolaryngologists office. The physical examination shows this enrollee has bilateral nasal valve collapse and narrowing. The enrollee also has clinical symptoms of nasal obstruction and has failed medical therapy. Though there is a deviated septum, the Latera implant would still be an option since the external and internal nasal valve are narrowed and the Breathe Right strips improved the enrollees symptoms. This indicates the Latera implants would accomplish the same goal, permanently. Therefore, this enrollee meets criteria for being a good candidate for bilateral insertion of Latera absorbable nasal implant stents. The Latera implant was approved by a governmental body.  It is approved for the use intended for this enrollee.Final Result: The reviewer determined that the requested service is likely to be more beneficial than any available standard therapy for treatment of the enrollees medical condition. Credentials/Qualifications: The reviewer is board certified in otolaryngology and are actively practicing. The reviewer is 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 72-year-old male enrollee has requested continued shaving of the skin, strapping of the ankle or foot, and/or debridement of the ulceration for treatment of his foot ulceration.  Findings:  The physician reviewer found that upon review of the information provided, the requested services are medically necessary for treatment of the patients foot ulceration. The primary goal in proper wound care is debridement of non-viable tissue and off loading the pressure to the ulcer site. During each treatment session, the providers notes document that the ulceration below the patient's left foot was debrided, there was enzymatic debriding, and antibiotic creams and off loading strapping were applied. Although musculoskeletal examination is not documented, the progress notes do provide sufficient description of the location and treatment of the ulcer. In the letter dated on the date in question, the provider states that the wound is 90% closed, which indicates that further treatment is still required. For these reasons, I have concluded that the requested services are medically necessary for management of this patients foot ulceration.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for lymphovenous bypass or lymphaticovenous anastomosis (LVA).Findings: Two out of three physician reviewers found that a lymphovenous bypass or LVA is likely to be more beneficial for you than any available standard therapy.Rockson states that no medications have been shown to alleviate lymphedema. Instead, standard treatments involve various physiotherapeutic interventions, such as decongestive lymphatic therapy. Decongestive lymphatic therapy relies heavily on manual lymphatic drainage combined with compression bandaging. Garza and colleagues state, LVA or lymphovenous bypass is a surgical procedure where lymphatic vessels in a lymphedematous limb are connected to nearby small veins and venules using microsurgical and super-microsurgical techniquesNumerous studies have been published which show improved symptoms and as much as 61% reduction in volume difference of the affected limb after LVA at one year. Additionally, Pereira and colleagues report, LVA is an effective treatment option to reduce the volume [of cellulitis] in the affected limb and to improve symptoms involved. Garza and Chang state, Benefits of [lymphovenous bypass] are its effectiveness in treating early-stage lymphedema of either the upper or lower extremity and having low complication profile. The International Society of Lymphology states, LVAs are currently in use at multiple centers around the world. These procedures have undergone confirmation of long-term patency (in some cases more than 20 years) and some demonstration of improved lymphatic transport (by objective physiologic measurements of long-term efficacy). Multiple LVAs in a single surgical site with both the superficial and deep lymphatics, allow the creation of a positive pressure gradient (lymphatic-venous) and evade the phenomenon of gravitational reflux without interrupting the distal peripheral superficial lymphatic pathways. In this case, the patient has used multiple conservative measures for control of her lymphedema, but the lymphedema has progressed despite these measures. LVA or lymphovenous bypass is accepted therapy for the treatment of post-mastectomy lymphedema. Therefore, the requested lymphovenous bypass or lymphaticovenous anastomosis (LVA) is likely to be more beneficial for treatment of the patients condition than any available standard therapy.Final Result: The reviewers determined that the requested service is likely to be more beneficial than any available standard treatment for the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer 1, reviewer 2, and reviewer 3 are board certified in plastic surgery. All reviewers 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 49-year-old female enrollee requested authorization and coverage of 50 semi-weekly psychotherapy sessions for a six-month period. The Health Plan denied the request indicating that the requested therapy is not medically necessary for treatment of the enrollees depression.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plans denial on the basis that the requested therapy is medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld

A 23-year-old female enrollee has requested Botox injections for the treatment of her recurrent headaches. Findings:  Three physician reviewers found that Botox therapy has been presented in the medical literature as an alternative treatment for managing migraine headaches. This treatment remains fairly controversial, and articles suggesting its efficacy as well as its lack of effect have been published in several peer-reviewed medical journals. This is an option that should be considered if more conventional treatments fail to provide adequate migraine prophylaxis. In this patients case, there is not enough evidence to justify the use of Botox since the medical records fail to provide documentation on prior treatments, including duration or migraine disability assessment questionnaire scores. Additionally, in the note that was submitted it further suggests that additional Botox treatments are not indicated for treatment of this patient.
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:  Two physician reviewers found that despite the lack of long-term studies proving an increased survival rate when tomosynthesis has been used as part of screening mammography the American College of Radiology (ACR) has urged the technique be removed from the investigational category due to the advantages it brings radiologists interpreting mammograms. This tomographic method often allows the reader to separate dense glandular elements from underlying mass/architectural distortion resulting in a decrease in callbacks and biopsies and increase in diagnostic accuracy and increase in detection of small cancers compared to when the study is done with only two-dimensional (2D) imaging. Thus, the addition of tomosynthesis to the usual 2D protocol was likely of greater benefit to the patient than had her exam been done with 2D imaging alone. Final Result: Two 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

The parent of a two-year-old male enrollee has requested authorization and coverage for speech therapy for treatment of the enrollees speech delay. Findings:  The physician reviewer found that the patient has an identified speech delay of 57% to 71%, in addition to a 57% delay in his pragmatics, a 43% delay in gestures and a 57% delay in play skills. Speech therapy is indicated with any delay greater than 25% (Law, et al.). Improvements have been noted following speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulty (Law, et al.). Treatment for language disorders is predicated primarily on the childs language profile and level of communication skills (Feldman and Messick). Children who participate in speech-language treatment show better improvement than those children who receive no treatment (Feldman and Messick). Gallagher, et al. evaluated speech and language interventions for preschool children with specific language impairment and found statistically greater improvement with intensive direct speech therapy delivered by speech and language therapists over an eight-month period when compared to no intervention or nursery-based intervention. Therefore, speech therapy is medically necessary to treat this patients speech delays.