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

The patient has requested authorization and coverage for bilateral transforaminal lumbar epidural steroid injection with fluoroguide and moderate conscious sedation.Conservative treatment has included multiple previous transforaminal epidural steroid injections at the L4-5 level with reported excellent pain relief for several months. Recent conservative treatment had included activity modification, medications, and home therapy. The Agency for Healthcare Research and Quality (AHRQ) comparative effectiveness study on injection therapies for low back pain concluded that epidural steroid injections for radiculopathy were associated with immediate improvements in pain. However, the AHRQ concluded that the benefits were small and not sustained, and there was no effect on the long-term need for surgery. The records do not include current clinical evidence of focal neurologic deficits correlated with imaging studies consistent with lumbar radiculopathy due to disc herniation. Additionally, the patient reports her current chief complaint as back pain, which is not a supported indication for an epidural steroid injection. All told, the requested bilateral transforaminal lumbar epidural steroid injection with fluoroguide and moderate conscious sedation 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 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: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for brand name Nuvigil 150 mg daily. The patient underwent an adequate normal in lab polysomnogram (PSG) with an apnea/hypopnea index (AHI) of zero events per hour, oxygen nadir of 95% and adequate sleep time. The PSG was followed by a multiple sleep latency test (MSLT), which noted that the patient had four naps with a sleep latency 7.5 minutes and no SOREM, which is consistent with a diagnosis of idiopathic hypersomnia. A negative MSLT for narcolepsy does not rule out narcolepsy when the clinical suspicion is high, as in this patients case. Nuvigil is an oral non-amphetamine wake-promoting agent, the R-isomer of racemic modafinil. Nuvigil and modafinil share many clinical and pharmacologic properties and are distinct from central nervous system stimulants. Nuvigil is supported as safe and effective for the treatment of excessive daytime sleepiness secondary to idiopathic central hypersomnia. The records document that treatment with modafinil 200 mg twice daily was inadequate to control the patients excessive daytime sleepiness. Moreover, the patient has a diagnosis of celiac disease, for which the provider recommended the brand name Nuvigil, which is gluten free. Given these findings, the requested brand name Nuvigil 150 mg daily 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 sleep medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Botox injections for treatment of his facial pain.  Two physician reviewers found that the Botox injections were not likely to be more effective for this patient than other available options. There is a lack of medical literature supporting the safety and efficacy of Botox injection for treatment of the patients medical condition. Furthermore, there is a lack of controlled studies supporting the safety and efficacy of Botox injection for refractory facial pain. For the reasons provided, the Botox injections at issue were not likely to be more effective than other modalities.  Final Result: Two reviewers determined that the services at issue were 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: All three reviewers are board certified in neurology and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement and prospective authorization and coverage for residential mental health treatment services for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found that there is a lack of support for the services at issue in this clinical setting. The patient was not a danger to himself or others. Although continuing to act out verbally, break boundaries, escalate arguments, and lack insight, the patient had shown improvement in all of these areas.  He was not aggressive or violent towards others.  He performed his ADLs and was cognitively intact. He did not show improvement in the area of school. However, this did not require the residential setting. This could perhaps be accounted for, at least in part, by his unmedicated state. He was medically stable, and his psychotropic medication management did not require the residential setting. The medication list had not reflected any changes. Although he continued to struggle with emotional lability and required ongoing intensive treatment to further develop coping skills, this did not require the structured environment of a 24-hour a day 7 days a week residential setting. The patient could have been treated at a lower level of care. In sum, the services at issue were not and are not medically necessary for treatment of this patient. 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: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for lidocaine patches 5%. Findings:  The physician reviewer found that  U.S. Food and Drug Administration (FDAs) official drug website states that the lidocaine patch is only approved for use in treating post-herpetic neuralgia. McColgan and colleagues stated that there has been no evidence to support the use of lidocaine patches for musculoskeletal pain.  A systematic review by Santana and colleagues evaluated the medical evidence supporting the use of lidocaine patches for chronic low back pain. The authors concluded, We found no randomized controlled trials with substantial evidence to support the use of 5% lidocaine patch in chronic low back pain.In this case, the patient has chronic low back pain due to lumbar radiculitis and facet joint arthropathy. Her records do not show any history of post-herpetic neuralgia or any complaints related to this condition. The records show that the patient has been prescribed lidocaine patches to treat musculoskeletal back pain. Currently, the FDA has not approved the patches for this use, and the recent reviews on this subject reinforce the lack of evidence for use of the lidocaine patches in musculoskeletal related chronic pain. Therefore, the requested lidocaine patches 5% are 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 anesthesiology with sub-specialty certification in pain medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 55-year-old male enrollee has requested use of a cold therapy unit for the treatment of his condition status post anterior cruciate ligament reconstruction surgery. Findings:  The physician reviewer found that cold as a therapeutic modality is commonly employed in the treatment of soft tissue and other orthopedic problems, but the evidence of efficacy is not clear. Bleakley and colleagues noted that there is some support for the use of cold as a passive analgesic modality, but further high-quality trials are needed to provide evidence-based guidelines for its use. Sauls suggests that contrary results in different studies indicate the need for further investigation. With regard to the use of cold after ACL surgery, a similar pattern exists. Raynor and colleagues state that there are reports of decreased pain with the use of cold in the post-operative period, but no improvement in range of motion or drainage. Konrath and colleagues indicate that randomized trials demonstrating objective benefits are still needed. Thus, there is a lack of consistent evidence demonstrating the necessity of cold therapy as a medically necessary modality, and even less data regarding the use of a cold therapy unit versus standard ice packs.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested a laparoscopic hysterectomy and bilateral salpingo-oophorectomy for treatment of her medical condition.  Findings:  The physician reviewer found that the submitted records support the requested services in this patients case.  This patient has had chronic pelvic pain, with endometriosis confirmed surgically.  This has been unsuccessfully treated with hormone therapy, which she is now unable to be used due to side-effects.  The current medical evidence supports the requested services in this clinical setting.  All told, the requested laparoscopic hysterectomy and bilateral salpingo-oophorectomy are medically indicated 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 obstetrics and gynecology 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 enrollee has requested coverage for 15 hours of applied behavior analysis (ABA) therapy per week for treatment of the enrollees autism. Findings:  The physician reviewer found that the submitted documentation demonstrates the medical necessity of the requested therapy in this patients case.  Applied behavior analysis (ABA) has been shown to be effective in treating behaviors associated with autism spectrum disorder.  Treatments based on operant principles of learning are more effective for reducing maladaptive behaviors than other alternative treatments.  Per the current medical evidence, studies have shown that ABA methods continue to result in positive outcomes for individuals with autism and intellectual disability.  Evidence-based studies have noted improvement in function in older children with autism spectrum disorder using intense ABA interventions.  Per Sallows and Graupner, although substantial gains are made after one year of ABA therapy when compared to controls, further gains have been noted in subsequent years.  All told, the requested 15 hours of ABA therapy per week are medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

A 48-year-old female enrollee has requested Botox injections for the treatment of her cervical dystonia. Findings:  The physician reviewer found that this patient has long-standing cervical dystonia with contraction of her posterior cervical muscles, sustained head tilt and a response to initial treatment with Botox documented in the medical records. The medical literature supports the use of Botox for cervical dystonia. There is sufficient evidence of the efficacy of Botox in this patient population to justify its use in this case. This patient has received Botox in the past with reported benefit. Thus, Botox is medically necessary and appropriate for treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Overturned

A 51-year-old female has requested endovenous chemical ablation, left leg, using CPT code 37799 x 2 units (two dates of service), and endovenous chemical ablation, right leg, using CPT code 37799 x 1 (one date of service), in addition to sclerotherapy, right leg, using CPT code 36471 for treatment of her varicose veins.   Findings:  Two physician reviewers found that the patient has a long standing history of bilateral lower extremity varicose veins who presents complaining of bilateral leg pain and swelling severe enough to require over the counter analgesic medication. She is status post left short saphenous ligation and stripping about 15 years ago. There is documentation of palpable pedal pulses bilaterally. On duplex there is no evidence of deep vein thrombosis (DVT) or superficial thrombosis. There is evidence of reflux in the right greater saphenous vein (GSV) below the knee and in the right lateral accessory vein. There are also numerous incompetent perforators bilaterally. The provider has recommended treatment consisting of endovenous chemical, ablation, left leg, using CPT code 37799 x 2 units (two dates of service), and endovenous chemical ablation, right leg, using CPT code 37799 x 1 (one date of service), in addition to sclerotherapy, right leg, using CPT code 36471.  This patients records include documentation of attempts at treatment for significant symptoms including use of medical grade compression stockings. There is documentation of palpable pedal pulses and the absence of DVT. There is documentation of reflux in the veins to be treated. Consistent with the peer-reviewed medical literature, injection of a sclerosing chemical into the larger refluxing veins is reasonable and appropriate in this patients case. The distal GSV is not an ideal site for surgical stripping due to nerve proximity. As such, the requested endovenous chemical ablation is likely to be more beneficial to this patient than standard alternatives. The provider makes a distinction between the large, deeper veins and the small reticular superficial veins. Although the documentation does not support the necessity of sclerotherapy of the small superficial veins, the sclerotherapy code would be appropriate for injection of sclerosant into the larger veins. Therefore, sclerotherapy of the larger veins bilaterally is likely to be more beneficial than standard therapies for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 70-year-old female enrollee has requested Byetta for the treatment of her type II diabetes mellitus.  Findings:  The physician reviewer found that Byetta is used with insulin in the endocrine community. The manufacturer will soon have FDA approval for its concomitant use with insulin as well. Byetta is medically appropriate and indicated in this patients case.
Appeal type: Medical Necessity
Decision: Upheld

A 38-year-old female enrollee has requested a panniculectomy for post gastric bypass treatment.  Findings:  The physician reviewer found that a panniculectomy may be medically necessary if the removed skin has a history of recurrent infections or is necrotic. The pannus would have to be quite large to cause lower back pain. The mere presence of a pannus and/or its psychological or physical burden on the patient does not automatically make its removal medically necessary.  The requested surgery would be performed to improve appearance rather than function, and a panniculectomy alone would only provide a minimal improvement in the appearance of this patient. Additionally, the patients panniculitis/intertrigo does not constitute an abnormal structure of the body.  The requested surgery would be performed to improve appearance rather than function, and a panniculectomy alone would only provide a minimal improvement in the appearance of this patient. All told, the requested panniculectomy is not reconstructive in nature and is not medically necessary for the treatment of this patient.The reviewed materials do not support the medical necessity of a panniculectomy in this patients case.
Appeal type: Medical Necessity
Decision: Overturned

The patient has requested authorization and coverage for an organ biopsy to completely rule out systemic amyloidosis. Evaluation of amyloid light-chain (AL) amyloidosis should involve a comprehensive assessment, as the condition can involve multiple organs. This patient notes multiple complaints that could be early symptoms of organ compromise by amyloid involvement. In addition to comprehensive organ directed evaluations, patients with a diagnosis of AL amyloidosis should undergo evaluation for systemic involvement by additional tissue biopsy. Additional tissue biopsies can include an abdominal fat pad aspirate, bone marrow, kidney, liver, and/or skin biopsies. A comprehensive work-up to determine whether she has systemic amyloidosis is essential to limit or reverse organ damage. Given these findings, the requested organ biopsy to completely rule out systemic amyloidosis is medically necessary for this patient. Final Result: The reviewer determined that the requested services are medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in oncology 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: Urgent Care
Decision: Overturned

A male enrollee requested ambulance transport services on an emergent basis.  Findings:  The physician reviewer found that review of the submitted clinical documentation demonstrates that a prudent layperson would have sought ambulance transport.  In this case, the patient called 911 due to abdominal pain associated with nausea and persistent vomiting. In this clinical setting, the patient should not have driven to the emergency department due to his pain, nausea, vomiting, and feeling like he may pass out. Thus, his symptoms were of sufficient severity that a prudent layperson would reasonably believe a delay in seeking medical attention would place his health in serious jeopardy or result in serious impairment to bodily functions or serious dysfunction of any bodily organ or part. All told, based upon the documentation provided for review, the patients symptoms did meet prudent layperson criteria for ambulance transport.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Lyrica 50 mg.Lyrica is U.S. Food and Drug Administration (FDA) approved for the following indications: neuropathic pain associated with diabetic peripheral neuropathy (DPN), postherpetic neuralgia (PHN), adult patients with partial onset seizures, fibromyalgia, and neuropathic pain associated with spinal cord injury. As the FDA has not approved the use of Lyrica for lumbar radiculopathy, its use in this case would be off label. A 2019 Cochrane review of Lyrica (pregabalin) for neuropathic pain in adults concluded that studies showed limited evidence of benefit in neuropathic back pain or sciatica, neuropathic cancer pain, or polyneuropathy. The North American Spine Society clinical guidelines for managing lumbar radiculopathy found that there was not strong evidence to recommend Lyrica for lumbar radiculopathy.In this case, the patient has a 10-year history of chronic lumbar radiculopathy and she has physical exam findings that are notable for a positive straight leg test bilaterally. A new lumbar MRI has been ordered to better evaluate her back and leg complaints. The patient has tried and failed gabapentin therapy and is currently using diazepam, ibuprofen, nortriptyline, methadone, Norco, and baclofen with little benefit. Under these circumstances, where there is limited evidence to support the use of Lyrica (pregabalin) for lumbar radiculopathy, the requested Lyrica 50 mg is not medically necessary to treat the patients medical condition.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 anesthesiology, with subspecialty certification in pain medicine, and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.