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

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for five-day inpatient dihydroergotamine (DHE) infusions. The submitted documentation supports the medical necessity of the requested services. This patient has refractory NDPH. He has been treated with numerous prophylactic medications, without resolution of his headaches. Beta-blockers are contraindicated, and multiple acute abortive medications for headache have been tried. There are several published studies documenting the efficacy of inpatient administration of DHE infusion given over several days in the treatment of refractory NDPH and status migrainosus. A study included 32 consecutive pediatric patients with refractory status migrainosus who received inpatient treatment with intravenous DHE. The authors noted upon discharge, 74.4% of the patients were headache-free. The authors concluded that DHE is very effective in treating and aborting an episode of status migraine and should be offered to children and adolescent patients who have failed their usual abortive therapy to prevent further severe disability that mainly affects their schooling and social activities. Therefore, five-day inpatient DHE infusions 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 neurology with special qualification in child neurology 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: An enrollee has requested authorization and coverage for speech therapy performed by a speech therapist who is certified in orofacial myology for treatment of the enrollees apraxia of speech. Findings:  The physician reviewer found that there is a lack of peer-reviewed literature showing that orofacial myofunctional therapy is effective for children with childhood apraxia of speech. Orofacial myofunctional therapy improves speech intelligibility in adults with persistent speech impairments. Typical speech therapy is not necessarily effective for childhood apraxia of speech. In this case, the patient has minimally understandable speech. Intensive speech therapy by a speech therapist with experience with childhood apraxia of speech is clinically indicated. A speech therapist certified in orofacial myology is not medically necessary as there is a lack of research supporting its treatment in children with childhood apraxia of speech. As such, the request for a speech therapist who is certified in orofacial myology is not medically necessary for treatment of the patients medical condition. 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 pediatrics with sub-specialty certification in developmental and 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

Nature of Statutory Criteria/ Case Summary:  The enrollee requested authorization and coverage for Aimovig Autoinjector 70 mg/ml.  The enrollee has a history of migraine headaches, asthma, and hypertension. She has been treated for migraines by her current primary care provider (PCP). She reported headaches a couple of times per week with throbbing and pain up to eight on a scale of one to ten, severe nausea, occasional phonophobia, and occasional aura. Her headaches are disabling and seem to be triggered by stress. She has been treated with different medications including Topamax, amitriptyline, gabapentin, Imitrex, valproic acid, atenolol, Bystolic, magnesium, and Depakote without long term success. She was referred to a neurology center for intractable chronic migraine and underwent Botox injections on three different dates. She reports the Botox did not prevent migraines. On a visit with her PCP, it is noted the enrollee gets up to fourteen migraines per month, which are associated with photophobia and phonophobia. The PCP noted multiple medications for prophylaxis (including the amitriptyline, Topamax, gabapentin, Depakote, Botox, and Magnesium) were tried. The record indicates the enrollee was utilizing Imitrex six to seven times per month.  She has been on multiple prophylactic medications, including amitriptyline, Topamax, gabapentin, Depakote and Botox.  The enrollee had also tried magnesium. According to the current peer-reviewed medical literature, Aimovig is FDA-approved as a calcitonin gene-related peptide receptor antagonist indicated for the preventive treatment of migraine in adults.  After review of all of the provided documentation, the information substantiates the enrollee has a diagnosis of migraine headaches.  She has tried and failed multiple other medications including amitriptyline, Topamax, gabapentin, Depakote, Botox, magnesium, Valproic Acid, Bystolic, and atenolol.    The enrollee has tried and failed all drug classes that have established efficacy in prevention of migraine headaches. Final Result: The reviewer determined that the requested services are medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in neurology and neuromuscular 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 47-year-old man with a history of exotropia/phoria. The patient underwent cataract surgery. In addition, he underwent treatment with Botox injections. There is a high incidence of exotropia in muscular dystrophy, which tends to worsen with time. The patient has requested authorization for Lasik surgery. The Health Plan has denied the patients request on the basis that Lasik surgery is not medically indicated.It is likely that after the patients left eye cataract surgery in 1994, his right eye vision slowly faded. An eye with poor vision is not utilized and tends to drift. It appears that the phoria progressed to a trophia. Following cataract surgery in his right eye in 1996, the patients vision was clear but the exotropia is so large he cannot maintain fusion. If the patients exotropia is to be relieved, surgery will be needed. Lasik surgery to correct the small amount of anisometropia is unlikely to improve the situation. It is only .75 or 1.00 diopter. The patients provider has indicated it is not large enough to account for the patients symptoms. Furthermore, Lasik surgery is not without risk. One of the common problems is dry eye, which the patient is already experiencing. Thus, the requested procedure may actually aggravate his condition and is not likely to result in significant improvement of his vision.Based upon the information set forth above, I have determined that the requested procedure is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 41-year-old female who is 56 weighing 304 pounds with a body mass index (BMI) of 48. The patient underwent Lap-Band surgery in 1998. At the time of surgery the patient weighed over 500 pounds. Her weight reportedly dropped to 180 pounds following the procedure. She has been experiencing weight gain and worsening of distal esophageal dilation. The patient is status post multiple Lap-Band adjustments. She wishes to undergo revisional gastric bypass surgery. The Health Plan has denied authorization for the requested procedure on the basis that it is not medically indicated for treatment of the patients medical condition.Review of the medical literature indicates revisional weight loss surgeries have a high complication rate. A patient who has failed a restrictive operation (Lap-Band) is more likely to fail another restrictive operation longer-term unless a malabsorptive element is added. The study cited above reported high incidence of protein and nutritional deficiency after revision of gastric bypass to distal gastric bypass.  Furthermore, a patient with a BMI of 48 may have a high failure rate after a restrictive procedure. A more suitable option may be a hybrid procedure such as duodenal switch. Removal of the Lap-Band is medically indicated to prevent any further esophageal dilation. Revisional gastric bypass is not likely to be of benefit and is not medically indicated for treatment of the patients medical condition. The patient should be evaluated for consideration of a duodenal switch procedure.Based upon the information set forth above, I have determined that the requested procedure is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Lyrica. This patient has been diagnosed with cervical radiculopathy and fibromyalgia. He has been treated with both duloxetine and gabapentin. The documentation notes that he had dizziness with duloxetine. The records do not document adverse reactions to gabapentin.  Fibromyalgia is a complicated chronic pain syndrome that requires both nonpharmacologic and pharmacologic therapies for optimal treatment. Patient education is a key part of treatment, and treatment recommendations include exercise. If education and exercise do not resolve symptoms, a tricyclic antidepressant may be appropriate. If a tricyclic antidepressant does not improve symptoms, Duloxetine is recommended. If these treatments fail to resolve symptoms, pregabalin (Lyrica) is recommended with gabapentin as an alternative. In this case, the patient has not failed treatment with a tricyclic antidepressant, and there is no documentation that he has attempted a home exercise program. Therefore, Lyrica 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 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: Overturned

A 57-year-old female enrollee has requested repeat Synvisc injections for treatment of her knee pain.  Findings:  Two physician reviewers found that the submitted clinical information indicates the patient received an initial course of Synvisc with relief for one year. Repeat treatment with Synvisc may be indicated for patients with continued pain in the knee due to osteoarthritis if relief of pain was obtained from a previous treatment course of Synvisc and at least six months have elapsed since previous injections. Based on the evidence provided, the patient met criteria for repeat Synvisc injections.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested laminoforaminoplasty with discectomy at C5-6, C6-7 (two-level Deuk Laser Disc Repair) for treatment of the enrollees neck pain with radiation.  Findings: Three physician reviewers found that the Peer-reviewed literature has found that endoscopic discectomy surgery is as effective as traditional discectomy in small volume studies. However, evidence based medical guidelines do not recommend endoscopic discectomy surgery for use in this clinical setting. Overall, peer-reviewed medical literature cites a lack of comparative studies and randomized controlled trials for this type of procedure in the cervical spine to support safety and efficacy. A study conducted a meta-analysis of 24 months of clinical results, and reported that the full endoscopic procedure for discectomy was as effective as traditional discectomy but cautioned that large-volume, well-designed randomized controlled trials with extensive follow-up are needed to confirm and update the findings of this analysis. This patient presents with persistent and worsening cervical radicular pain, limiting his ability to perform activities of daily living. Detailed evidence of a recent, reasonable and/or comprehensive non-operative treatment protocol trial and failure has been submitted. Providers have recommended anterior cervical discectomy and fusion at the C5-6 and C6-7 levels for imaging findings of spinal canal and bilateral neuroforaminal stenosis. Given the lack of large volume, long-term peer-reviewed outcome studies to support the use of this procedure for this patient, the requested laminoforaminoplasty with discectomy at C5-6 and C6-7 (two-level Deuk Laser Disc Repair) is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: Three 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: All three physician reviewers 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: Experimental/Investigational
Decision: Upheld

A 62-year-old female has requested artificial disc insertion at C6-C7 for treatment of her neck pain.  Findings:  Three physician reviewers found that the patient is status post cervical fusion.  Six months ago she reported electric shock-like sensations going down from the neck and up the extremities, and this is increased by extension.  The medical records noted no clumsiness, no myelopathy, and no weakness.  She denied incontinence.  The provider noted that a prior MRI scan showed disc fragments at C6-7 and a collapsed disc at C7-T1.  In this case, the requested procedure is not likely to be more efficacious than other treatment options.  She reports electric shock-like sensations that are increased with certain neck movements.  The patient has disc protrusions below her fusion, although she has no radicular or myelopathic symptoms.  The long-term efficacy and safety of the requested procedure has not been established in this clinical setting.  Although there are some promising reports of short-term safety and efficacy, there is a lack of long-term data supporting the requested artificial disc insertion in this situation.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for an autologous mesenchymal stem cell regenerative medicine procedure. Researchers note that while there are Level I studies to support the use of platelet-rich plasma (PRP) and mesenchymal signaling cells (MSC) injections for discogenic pain, facet joint injections with PRP, epidural injections of autologous conditioned serum and epidural prolotherapy, and PRP and prolotherapy for sacroiliac joint pain, no studies to date have been published on the use of MSC injections administered via the sacroiliac joint. Researchers report that the available evidence regarding the use of MSCs has been assessed as Level III (on a scale of Level I through V). The authors did not note evidence supporting the use of MSCs in sacroiliac joint injections. In this case, the patient has sacroiliac joint-related pain and has undergone two joint injections with mixed results. Given the weak nature of the evidence in current medical literature supporting the use of MSC injections, and the lack of studies evaluating MSC injections for sacroiliac joint related pain, the requested service is not medically indicated. Therefore, an autologous mesenchymal stem cell regenerative medicine procedure is not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested service 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for IVIG (intravenous immune globulin) treatment with Octagam (HCPCS-J1568). Based on the current medical literature and the submitted documentation, there is a rationale and sufficient scientific data in the literature to support the use of high-dose IVIG for the treatment of this patients condition. There is sufficient outcome data available from case reports in published peer-reviewed literature that substantiates the safety and efficacy for the use of IVIG for post infectious autoimmune encephalitis. IVIG has shown benefit and is generally recognized by the medical community as effective and appropriate for this condition. This patients records document that prior treatment with IVIG resulted in a clinically meaningful response. Thus, the IVIG treatment with Octagam (HCPCS-J1568) is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.One reviewer found that the IVIG treatment with Octagam (HCPCS-J1568) is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: Two of the three reviewers determined that the requested medication is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications:  One reviewer is board certified in pediatrics and neurology with specialty qualification in child neurology and is actively practicing. One Reviewer is board certified in pediatrics with sub-specialty certification in pediatric infectious disease and is actively practicing.  One Reviewer is board certified in pediatrics with sub-specialty certification in pediatric infectious disease and is actively practicing.  All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 36-year-old female enrollee has requested authorization and coverage of cervical epidural injections for the treatment of back pain.The Health Plan denied the enrollees request indicating that the requested treatment is not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer upheld the health plans denial on the basis that the requested injection is not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a one-year, six-month-old female enrollee has requested physical therapy services for treatment of the enrollees right sided torticollis. Findings:  The physician reviewer found that in the medical literature, Nilesh and Mukherji evaluated treatments for congenital muscular torticollis. The authors noted that early physical therapy is initiated if there is any lack of rotation from fibrosis. The records indicate this patient had a head tilt to the right with her face turned to the left, indicating a right congenital muscular torticollis and flattening of the cranium along the left occiput. The patient was treated with physical therapy for muscle strengthening and range of motion. She was noted to have improved craniofacial asymmetry. However, she continued to have a head tilt to the right when supine, sitting, and standing. The medical records provided for review demonstrate the patients neck range of motion had not improved with physical therapy. Thus, additional physical therapy services provided during the specified timeframe were not medically necessary for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 54-year-old male enrollee has requested below the knee amputation using the Ertl (bone bridge) procedure for treatment of his traumatic arthritis of ankle and trauma induced aseptic necrosis of the ankle.  Findings:  Two physician reviewers found that in a study by Lewandowski and colleagues, the authors stated that, symptomatic distal tibiofibular instability is a known complication of trauma-related transtibial amputations. The authors reported that recent studies have suggested an increase in complication and reoperation rates in transtibial amputations that received a bridge synostosis compared with standard transtibial amputations. In a report by Kingsbury and colleagues, the authors stated that, although some evidence indicated that patients with a bone bridge have improved loading at higher speeds, a regression of all patients walking at self-selected speed indicates that as residual limb length increases, loading increases regardless of amputation type. Thus, our data suggest it is important to preserve residual limb length to allow for improved loading in terminal stance. Overall, the requested Ertl bone bridge procedure does not have sufficient long-term studies to demonstrate the overall efficacy and safety of this device. Moreover, the Ertl procedure has not been demonstrated to be equivalent or superior to standard therapies in long-term studies. Therefore, the requested services are not likely to be more beneficial for treatment of this patients medical condition than any available standard therapy.