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

A 45-year-old female enrollee has requested physical therapy services including therapeutic ultrasound for the treatment of her temporomandibular joint dysfunction. Findings:  Two physician reviewers found that the treatment of temporomandibular joint (TMJ) dysfunction has shown some response to PT. Although physical therapy is commonly used to treat this disorder, there is little published data from clinical trials comparing different methods of physical therapy. Most reports are anecdotal. A study by Gray and colleagues reported on the use of four different physiotherapy modalities in the management of this problem and compared them with a placebo group. Short-wave diathermy, megapulse, ultrasound and soft laser therapy were tested. The authors noted no statistically significant difference in the success rate between any of the four methods, but each was significantly better than placebo treatment. Mohl and colleagues stated in their study that evidence supporting the conclusion that therapeutic ultrasound alone is useful for the treatment of TMJ is lacking. The evidence as noted in another study by Hotta and colleagues concluded that a conservative approach involving counseling and PT resulted in improvement in parameters of pain and jaw function in patients with myofascial pain, but there were no significant differences between the groups receiving four weeks versus six weeks of PT. In the case of this patient, she had already been participating in physical therapy prior to the five months of therapy at issue here. It appears from the few studies that have been performed that the safety and efficacy of physical therapy including ultrasound for the treatment of TMJ has yet to be established and its value in this setting remains unproven. In this case, the patient received five months of physical therapy including ultrasound without objective documentation of measurable progress.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 32-month-old male born full term. At five weeks of age he was hospitalized for fever and bloody diarrhea. He had delayed motor development with hypotonia at two months. He was not fixing or tracking appropriately. At four months, the patient was seen by a neurologist who documented truncal hypotonia and hyperreflexia as well as visual impairment. An MRI showed diffuse mild atrophy or underdevelopment of the brain. A second opinion regarding the MRI described delayed myelination. The most recent neurological exam in December 2004 was normal.The developmental pediatrician notes on the December 2004 evaluation the difficulty in the area of social communication. She has also noted difficulties with attention shifting and awareness of other interests. Despite these issues the pediatrician does not place the patients diagnosis in the autistic spectrum disorders. She has recommended completion of the medical workup to rule out other causes for the communication skill deficiency. She has also recommended twice weekly occupational therapy.At issue is whether twice weekly occupational therapy is medically necessary.There is insufficient literature to support or refute occupational therapy for children with developmental delay. Review of the patients history reveals documentation of delayed myeliniation and a neurological exam, which has progressed from truncal hypotonia, vision disturbances, hyperreflexia and significantly delayed fine and gross motor skills at four months of age, to a normal neurologic exam at two years of age. Based on the developmental pediatrician evaluation and occupational therapy evaluation in December 2004, the patient now has primarily educational/developmental issues. The delays in age appropriate ADLs appear to be related to the delay in maturation of his central nervous system (though, this is not to say they will resolve spontaneously) and to his delay in social communication. These issues are not historically considered medical in nature; prior to the age of three such issues fall under the auspices of a regional center, and after age three they are considered educational in nature. Therefore, I have determined that the requested therapy is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  The enrollees representative has requested authorization and coverage for Diagnostic Genetic Testing. Review of the medical record indicates an enrollee who has been diagnosed with autism, as well as intellectual impairment.  The enrollee was nonverbal at baseline so her parents are typically her source of information.  The enrollee does have a history of cataracts, urinary incontinence, rectal bleeding and abnormal plasma amino acids.  She has undergone previous genetic testing revealing chromosome every 4 deletion.  The submitted documentation includes multiple notes to include previous hospitalizations. The submitted documentation detailed the enrollee has undergone MicroArray testing as well as FISH testing.  The enrollee has had an increase in complications to include a ruptured esophagus with intractable emesis and has had cataract removal over the past few years.  Current peer-reviewed literature indicates mitochondrial genetic disorders may be caused by changes in either the mitochondrial DNA or nuclear DNA. Most DNA is packaged within the nucleus of each cell. However, mitochondria contain a small amount of their own DNA. Mitochondrial genetic disorders can be inherited but may be difficult to diagnose. Literature indicates when a mitochondrial genetic disorder is suspected but the signs and symptoms do not suggest a specific diagnosis a more extensive workup may be required. In the same cases testing levels of certain substances in the blood or cerebrospinal fluid may be appropriate.  In this case, the records show the enrollee had previously undergone genetic testing revealing a Q4 deletion.  The patients representative requested additional testing for possible oxidation phosphoric ablation defect, possible nonketotic hyperglycemia, or a mitochondrial disorder.  However, the records do not demonstrate how this will change the treatment plan given the enrollee has undergone multiple extensive work-ups, and results from specialists such as urology were not provided.Final Result: The reviewer determined that the service at issue is not medically necessary for treatment of the enrollees condition. Credentials/Qualifications: The physician reviewer is board certified in Clinical Cytogenetics and Clinical Genetics 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested coverage for L4-5 artificial disc replacement. Findings:  The physician reviewer found that there is sufficient support for the requested services in this patients case.  The U.S. Food and Drug Administration (FDA) approval for the ProDisc-L total disc replacement states that this device is indicated for spinal arthroplasty in patients who are skeletally mature, have degenerative disc disease at one level in the lumbar spine from L3 to S1, have no more than grade 1 spondylolisthesis at the involved level, and have had no pain relief after at least six months of non-surgical treatment. FDA exclusions include bony lumbar spinal stenosis and isolated radicular compression syndromes, especially due to disc herniation.  A study found that patients with degenerative disc disease undergoing either total disc replacement or circumferential arthrodesis maintained significant improvement during the five-year follow-up.  The total disc replacement group had significantly better improvement on some scales.  This patient has had persistent and worsening low back pain that has failed to respond to at least six months of comprehensive conservative treatment.  Functional difficulty is documented in activities of daily living and work ability.  There is imaging and discogram confirmation of single level degenerative disc disease at L4-5, with grade 1 or less spondylolisthesis at the involved level, and no evidence of spinal stenosis or nerve root compression due to disc herniation.  The patient meets the generally accepted standards of medical practice for lumbar artificial disc replacement. Therefore, the requested L4-5 artificial disc replacement is medically indicated for the treatment of this patient.Final Result: The reviewers 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: Physician reviewer number one 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the brain imaging tomographic scan for evaluation of the enrollees chronic fatigue. Findings:  Two physician reviewers found that the SPECT scan is a functional test of brain metabolism and has been used for a number of clinical neurologic and psychiatric disorders. In this case, the patient has chronic fatigue syndrome. The medical records provided for review fail to include a rationale for the SPECT scan provided in this case. The patient presented with subjective symptoms, however there were no significant objective findings documented except for adrenal insufficiency which was poorly responsive to cortisone supplementation. There is a lack of medical literature supporting the SPECT scan in the diagnosis of neurologic or psychiatric disorders, except for some specific conditions such as dementia and brain injury. All told, the brain imaging tomographic scan performed was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.  Final Result: The reviewers determined that the service at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Reviewers 1, 2 and 3 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: Upheld

The patient is a 34-year-old female with a history of right ankle fracture six years ago. She underwent hardware removal in February 2004. Since removal of the hardware she has been walking with an SPC and Cam Walker. She continues to have pain. X-rays have not demonstrated the etiology of her continued pain. She began physical therapy in August 2004 and therapy notes indicate the patient has difficulty standing for long periods of time. Her quadriceps strength was rated as 3+/5 with no abnormality in her upper extremity strength noted. In addition, there is no indication from the patients orthopedist that the patient is non-weight bearing. The patient is seeking authorization for a power-operated vehicle (POV). The patient does not meet nationally accepted medical necessity criteria for authorization of a POV. The patient is not bed or chair confined. In relation to her ankle fracture, there is no indication the patient is currently non-weight bearing. Furthermore, there is no indication the patient cannot operate a manual wheelchair. As such, there is no evidence a POV is medically necessary for this patient. Therefore, I have determined the requested equipment is not medically necessary for the patients mobility. The Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Cologuard stool testing for evaluation of the enrollee, who underwent routine colon cancer screening.   Findings:  2/3 of the physician reviewers found that the physician reviewer found colorectal neoplasms shed DNA in the stool. The DNA can be isolated and tested for the presence of mutations and epigenetic changes acquired during carcinogenesis. Cologuard is a second generation stool DNA test. Cologuard has been approved by the U.S. Food and Drug Administration as a screening test for colorectal carcinoma to be followed, when abnormal, by diagnostic colonoscopy. This test may be appropriate for asymptomatic patients, 50 to 84 years of age, who are at average risk for colorectal cancer. This patient is a high risk for sedated colonoscopy due to her extensive neurologic history. Therefore, Cologuard stool testing provided was likely to have been of greater benefit than other modalities for evaluating this patient. Final Result: 2/3 of 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 number one 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.Physician reviewer number two 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.Physician reviewer number three 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for sacroiliac (SI) joint radiofrequency ablation (RFA). In the documentation available for review, the provider states the patient had two weeks of pain relief after an injection. However, the medical literature suggests that radiofrequency ablation should be performed after a diagnostic block with local anesthetic alone and a pain diary with notations of medication usage. This patients records do not include documentation that this procedure was followed. In addition, the most recent physical examination by the provider is not specific to SI joint dysfunction. Therefore, SI joint RFA is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings:  Three physician reviewers found SI joint RFA 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 SI joint RFA is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in anesthesiology with sub-specialty certification in pain medicine 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: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Opdivo (nivolumab). The U.S. Food and Drug Administration (FDA) approves the use of Opdivo (generic name nivolumab), as a single agent or in combination with ipilimumab, for the treatment of microsatellite instability-high or mismatch repair deficient metastatic colorectal cancer that has progressed following treatment with a fluoropyrimidine, oxaliplatin, and irinotecan. The combination of regorafenib and nivolumab is not supported by the FDA or under the National Comprehensive Cancer Network (NCCN) guidelines for the treatment of rectal cancer. In this case, the patient has stage IV colon cancer. Given that current medical literature does not support the use of nivolumab in combination with regorafenib, the requested medication is not medically necessary. Therefore, Opdivo (nivolumab) is not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certifications in medical oncology and hematology 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 10-year-old male has requested speech therapy and occupational therapy for treatment of his pervasive developmental disorder. Findings:  The physician reviewer found that speech therapy provides professional help and guidance in communication development for individuals with autism spectrum disorders (Volkmar, et al.). Language skills make a significant difference in the ability of children to control their environment especially with social skills deficits. This patient is likely to benefit from speech therapy as part of a dedicated intervention program. Occupational therapy is indicated when deficits exist in functional skills or occupational performance as well as in areas of self-maintenance and activities of daily living (Dawson, et al., Baranek; and Case-Smith, et al.). This patient has a low overall adaptive behavior composite. The goal is to enable the patient to participate in everyday activities including taking care of oneself (dressing, bathing, toileting) and to help the patient develop skills such as posture and coordination. All told, the patient is an appropriate candidate for occupational therapy, a medically necessary modality in this setting.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 58-year-old male who has been experiencing recurrent vertigo, unsteadiness, disequilibrium, and ataxia since 2000. The patient reports significant disequilibrium and unsteadiness. An MRI documented cerebellar atrophy. Otoscopy revealed both external auditory canals were clear and tympanic membranes were visible an intact. Microscopic examination was normal. The patient underwent a computerized dynamic posturography resulting in a composite score of 40. Vestibular rehabilitation was then recommended. A request has been made for reimbursement for the computerized dynamic posturography, which the Health Plan has denied.The Health Plans denial should be upheld. There are no recent articles to establish computerized dynamic posturography as a sensitive or specific tool in diagnosing the cause of disequilibrium. Additionally, there is no available data regarding the health outcome effects of treatment decisions based on dynamic posturography. Thus, the clinical usefulness of computerized dynamic posturography remains unproven. Its use in the management of this patient was not more beneficial than established alternative tests. Accordingly, I have determined a computerized dynamic posturography was not medically necessary for evaluation of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

A 43-year-old female enrollee requested authorization and coverage of gastric bypass surgery for the treatment of morbid obesity.  The health plan denied the enrollees request indicating that the requested surgery is not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer overturned the health plans denial on the basis that the requested procedure is medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

A 29-year-old male enrollee requested authorization and coverage of Lamisil. The Health Plan denied the request indicating that the requested medication is not medically necessary for treatment of the enrollees onychomycosis.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested medication is not medically necessary at this time.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  The parent of an enrollee has requested residential treatment for treatment of the enrollees behavioral health conditions. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  The patient was not a danger to himself or others.  He was medically and psychiatrically stable.  He was working in school and actively participating in his therapies.  He had greatly improved in his behavior and was developing insight.  There was no evidence to show that returning him to his home environment would be detrimental to his continuing treatment.  During the dates of service in dispute, he could have safely and effectively been treated at a lower level of care.  All told, residential treatment was not medically indicated for the treatment of this patient. 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: Medical Necessity
Decision: Overturned

A 43-year-old male enrollee requested authorization and coverage of the medication Actiq. The Health Plan denied the request indicating that the requested medication is not medically necessary for treatment of the enrollees pain.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plans denial on the basis that the requested medication is medically necessary.