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

Nature of Statutory Criteria/Case Summary: An enrollee requested authorization and coverage for scar revision surgery for treatment of the enrollees scars and not reconstructive in nature. Findings:  The physician reviewer found this patient presents with evidence of symptomatic keloids/hypertrophic scars of the breasts, abdomen and umbilicus that is confirmed by review of the photographs and medical records. She has significant pain and tenderness associated with her scars that has failed conservative management with topical creams. The patient has a functional impairment directly related to an abnormal result from surgical intervention. Thus, resection and revision of her scars is medically necessary. In addition, the patients condition constitutes an abnormal structure of the body as she does not have normal scarring. Moreover, the planned surgery would help to improve her functional impairment of pain and approximate a more normal appearance of the scars with a more than a minimal improvement in the patients appearance. All told, the requested scar revision surgery is supported as medically necessary and reconstructive in nature for treatment of this patients keloid scars. Final Result: The reviewer determined that the requested surgery is medically necessary for treatment of the patients medical condition and reconstructive in nature. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in plastic 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

This patient is a 59-year-old male with osteoarthritis involving the left knee. He received his first series of hyaluronan injections in 2002, which helped to relieve the pain in his knee. He received two additional series of hyaluronan injections over the past few years, both with positive results. At his point in time, his pain has returned and he has requested authorization for a fourth series of injections with Supartz. The Health Plan denied this request on the basis that Supartz therapy is not medically necessary for treatment of his osteoarthritis.The patient has achieved significant pain relief with hyaluronan injections. There have been no documented side effects or other complications from the therapy over the past several years. He is attempting to delay knee replacement surgery as long as possible. Repeat hyaluronan injections are medically reasonable and appropriate at this time to alleviate his pain and postpone surgical intervention. Therefore, I have determined the requested Supartz injections are medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
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 more than 40 hours per week of applied behavioral analysis (ABA) services for treatment of the autism spectrum disorder.  Findings:  The physician reviewer found that the request for more than 40 hours per week of ABA services provided was not and is not medically necessary for the treatment of the patients medical condition. The records show that the patient has been documented as making progress of his reported problematic behaviors. In addition, he does not have severe behaviors such as aggression or significant self-injury that need to be targeted by more than 40 hours per week of direct ABA therapy. The gains made toward developmental norms and behavioral goals can be maintained at the ABA hours authorized by the Health Plan. All told, the services at issue were not and are not medically necessary for treatment of the patients medical condition. 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 pediatrics and 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested Harvoni for 12 weeks for treatment of his chronic hepatitis C virus genotype 1a.   Findings:  Three physician reviewers found that as per the American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) guidelines, all patients with chronic active hepatitis C are eligible for treatment and should be treated with U.S. Food and Drug Administration (FDA) approved antiviral therapy regardless of fibrosis score. Successful hepatitis C treatment results in sustained virologic response (SVR), which is tantamount to virologic cure, and is expected to benefit nearly all chronically infected patients. The fixed dose combination ledipasvir-sofosbuvir (Harvoni) is FDA approved for the treatment of chronic hepatitis C genotype 1 in both treatment-naive and treatment-experienced patients. Given this support, the requested 12 week course of Harvoni is medically necessary for treatment of this patients hepatitis C virus.   Final Result: Three reviewers 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: All three reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 47-year-old female enrollee has requested C5-6 artificial disc replacement, utilizing ProDisc-C for treatment of her disc osteophyte complex at C5-6.  Findings:  Two physician reviewers found that this patient with chronic left upper extremity pain and numbness has an abnormal MRI scan at C5-6 that may correspond to her complaints. The FDA approved ProDisc-C for marketing in 2007 contingent on a 7-year post approval study. This study has neither been reported nor concluded. The studies of Delamarter and colleagues provided encouraging findings, but fail to have 7-year, and 10-year long-term studies demonstrating safety and effectiveness. Similarly, Boselie and colleagues noted that, use of these disc prostheses should be limited to clinical trials. Results are too early given absence of truly long-term results. Madigan and colleagues stated that nucleus replacement and motion sparing technology are too new to have demonstrated long term data regarding their efficacy. All told, the use of ProDisc-C is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for 4 additional lidocaine trigger point injections. The submitted documentation supports the medical necessity of the requested services. A trigger point is a focus of hyperirritability in a tissue that, when compressed, is locally tender and, if sufficiently hypersensitive, gives rise to referred pain and tenderness. Trigger points may also give rise to referred autonomic phenomena and distortion of proprioception. Once trigger points are formed, they are thought to be self-perpetuating. Although trigger points may cycle between active and latent, they do not typically self-resolve. Trigger point injections have been shown to provide relief. In this case, the patient has masticatory myalgia. Contributing factors to the patients masticatory myalgia are abnormal skeletal and dental alignment and structural abnormality of her TMJ. Given this, the requested additional trigger point injections will likely provide the patient with relief as one element of her oral surgeons recommendations. Under these circumstances, 4 additional Lidocaine trigger point injections are medically necessary for treatment of the patients medical condition.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 oral and maxillofacial 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

A female enrollee requested octreotide (Sandostatin) 40 mg injections for medical treatment of her polycystic liver disease.   Findings:  The physician reviewer found that the requested Sandostatin is supported as medically necessary. In the medical literature, Gevers and colleagues reported that in patients with polycystic disease, young female patients appear to have the greatest benefit from treatment which might avert the progressive course of the disease in this specific group. All told, the requested octreotide (Sandostatin) 40 mg injections are medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested Sovaldi with ribavirin for 12 weeks for treatment of the enrollees hepatitis C.  Findings: The physician reviewer found that according to joint guidelines issued by the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America, all patients with chronic hepatitis C should be treated except those with life expectancy less than 12 months due to non-liver-related conditions. The guidelines recommend treatment with Sovaldi/Daklinza or Epclusa for treatment-naive, genotype 2 patients.  The medication regimen of Sovaldi and ribavirin is no longer recommended.  The guidelines cite data showing that delay in treatment may result in decreased survival. For these reasons, although hepatitis C treatment is necessary, the requested medication regimen of Sovaldi and ribavirin for 12 weeks is not medically necessary for the treatment of this patients hepatitis C infection.Final Result: The reviewer determined that the requested medication regimen 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 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 52-year-old female enrollee has requested prescription medication carisoprodol (Soma) for treatment of her pain. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication.  The current standard of care for chronic pain is treatment in a multidisciplinary practice, including massage therapy, physical therapy and behavioral therapy to help reduce pain.  Muscle relaxants are considered adjunctive to this therapy. Centrally-acting muscle relaxants, such as Soma, are associated with a high risk of dependence and tolerance.  Therefore, long-term administration is not recommended.  Bailey and Briggs performed a retrospective study on carisoprodol and noted the potential for abuse and recommended that the drug be included in comprehensive drug screening.  The current medical evidence does not support the requested medication in this clinical setting.  All told, the prescription medication carisoprodol (Soma) is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for chiropractic services for treatment of the enrollees medical condition.  Findings:  The physician reviewer found that This patient has received extensive chiropractic care, but he has not made significant improvement.  Despite continued frequent chiropractic visits, his pain levels do not improve and sometimes worsen.  There is a lack of evidence indicating that chiropractic treatment is helping the patient improve his condition.  This is a chronic injury, and chiropractic care is not considered active care.  There is a lack of further clinical improvement to be expected from ongoing therapy.  The records do not document objective functional improvement.  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 chiropractic care 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

Findings:  The physician reviewer found that The patient has requested authorization and coverage for acute inpatient rehabilitation. The records document that this patient was hospitalized with sepsis. The patient presented with an infected surgical wound at the right hip and proximal femur surgical site, as well as pneumonia. The patient underwent definitive surgical intervention, and was started on antibiotics, consistent with the current recommendations in the medical literature and guidelines (Prescott and Angus). The patient briefly required pressor therapy early in the postoperative period, but has been medically stable since that time. Functionally, the patient improved to require standby assistance for transfers and short distance ambulation with a walker. The patient continues to require some additional basic rehabilitation for reconditioning. However, there is a lack of documentation of any complex or intense rehabilitation needs. The patient can receive rehabilitation therapy services in a less intensive treatment setting than acute inpatient rehabilitation. Moreover, the patient does not have any reported ongoing intensive medical or skilled nursing needs that require treatment at the acute inpatient rehabilitation level of care (Mayer, et al.). Given these findings, the requested acute inpatient rehabilitation 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.
Appeal type: Experimental/Investigational
Decision: Upheld

A 36-year-old female enrollee has requested reduction of inferior turbinates by coblation (CPT code 30140) submucous resection inferior turbinate, partial or complete, any method for treatment of her moderate obstructive sleep apnea. Findings:  Two physician reviewers found that in this patients case, the requested services are not likely to be superior over other available treatment modalities.  The peer-reviewed medical literature suggests subjective improvement of symptoms of sleep disorder, but there is a lack of evidence of any objective demonstration of improvement of outcomes. Sundaram and colleagues reference evidence of outcomes of surgery, but there is a lack of peer-reviewed articles that demonstrate substantial improvement of the apnea/hypopnea index. Although the clinical evidence and peer-reviewed literature listed show some improvement of nasal symptoms, there remains a lack of documentation showing that the radiofrequency ablation of hypertrophied inferior turbinates improves sleep patterns.
Appeal type: Medical Necessity
Decision: Overturned

A 39-year-old male enrollee has requested for Crestor for treatment of his hyperlipidemia. Findings:  The physician reviewer found that a lipid-lowering agent should be discontinued if there is significant intolerability, either in the form of patient side effects or abnormal laboratory data. Therefore, it is medically appropriate for the patient to continue on Crestor. The use of this lipid-lowering medication is supported by the American College of Cardiology (ACC) guidelines for patients with dysplipidemia.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested positron emission tomography (PET) with concurrently acquired computed tomography (CT); skull base to mid-thigh and fluorodeoxyglucose for evaluation of the enrollees rectal cancer. Findings: The physician reviewer found that the review of the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested diagnostic procedure. The records provided for review do not show a treatment plan for surgery, nor is the provider planning new chemotherapy or radiation therapy. The medical records do not indicate any evidence of possible recurrent neoplasm. In addition, previous imaging does not show results suspicious or inconclusive for recurrent neoplasm. Therefore, the request for PET with concurrently acquired CT; skull base to mid-thigh (CPT 78815) and fluorodeoxyglucose F-18 FDG (HCPCS A9562) has not been established as medically necessary for evaluation of the patients medical condition.Final Result: The reviewer determined that the requested diagnostic procedure is not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in diagnostic radiology 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 7-year-old female enrollee has requested continuation of 15 hours per week of outpatient psychotherapy/behavioral therapy for treatment of the enrollees autism.  Findings:  The physician reviewer found that in the medical literature, Eikeseth and colleagues conducted a controlled study of behavior modifications in young patients with ASD and other behavioral disordered children. The authors reported significant long-term improvement in behavior, speech, performance, and even IQ in the treated versus the non-treated groups. These findings were consistent with Sallows and Graupners trial with longer follow-up. In addition, Myers and colleagues demonstrated supportive approaches that focus on 1-to-1 floor-time play sessions and other strategies to enhance relationships and emotional and social interactions to facilitate emotional and cognitive growth and development in young patients with ASD. The authors noted that the goal of therapy is to engage the patient in a social relationship so that he discovers the value of positive interpersonal activity and becomes more motivated to learn the skills necessary to sustain these relationships. The value of outpatient psychotherapy/behavioral therapy in this patient population is substantiated by controlled and uncontrolled studies. The therapy described for this patient is attempting to establish social interactive skills and the records demonstrate moderate progress. While the patient is an appropriate candidate for outpatient psychotherapy/behavioral therapy, 15 hours per week of therapy is an excessive amount and is not medically necessary for this patient. One hour of outpatient psychotherapy/behavioral therapy per weekday (five hours per week) is medically appropriate and is likely to be most effective in this setting. Since psychotherapy/behavioral therapy is medically necessary for this patient, it should be approved but should be limited to five hours per week.
Appeal type: Experimental/Investigational
Decision: Upheld

A 38-year-old male enrollee has requested transcranial magnetic stimulation (TMS) treatments for treatment of his major depression.  Findings:  Three physician reviewers found that transcranial magnetic stimulation (TMS) was first introduced in 1985 as a novel method of non-invasive stimulation of the brain. The peer reviewed medical literature addressing the topic of antidepressant treatment consists of varying reports on the efficacy, especially long-term and potential side effect profile along with patient selection, for benefit of repetitive TMS. In 2007, Gross and colleagues provided an updated meta-analysis of studies related to this treatment modality. The authors concluded that although results suggest that TMS has significant antidepressant effects, larger multicenter studies are still necessary and are indeed underway to confirm these trends. From their perspective, such treatment is advantageous, but continued trials are required to advance this treatment from the experimental phase into standard therapy. In Lam and colleagues, the authors concluded that for patients with treatment resistant depression, TMS appears to provide significant benefits in short-term treatment studies. However, the relatively low response and remission rates, the short durations of treatment, and the relative lack of systematic follow-up studies suggest that further studies are needed before TMS can be considered as a first-line monotherapy treatment for treatment resistant depression. Further, Gershon and colleagues also reported positive responses of TMS as an antidepressant treatment, but cautioned that the need for verification and standardization of best practices and patient selection are still uncertain. According to their review, the absence of psychosis, younger age, and certain brain physiologic markers might predict treatment success. However, the technical parameters possibly affecting treatment success including intensity and duration of treatment requires ongoing systematic testing of this modality.
Appeal type: Medical Necessity
Decision: Overturned

A 64-year-old female enrollee has requested the medication Byetta for treatment of her diabetes. Findings:  The physician reviewer found that the submitted clinical evidence demonstrates the patient has experienced improvement in her health since she began taking Byetta. She has lost weight, and as a result has less joint pain. She also experienced improvement in her glucose variability. Furthermore, the patients hemoglobin A1C dropped to 5.7% on Byetta without significant hypoglycemia.
Appeal type: Medical Necessity
Decision: Upheld

The father of a four-year-old male enrollee requested reimbursement for food allergy testing performed on 6/30/03. The Health Plan denied the request indicating that the services at issue were not medically necessary for treatment of the enrollees food allergies.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the services at issue were not medically necessary.