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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for wireless capsule endoscopy.  Findings:  Two physician reviewers found that in this case there is a concern that Crohns disease is affecting the small intestine and caused the patients obstruction.  However, Crohns disease is one possible cause for obstruction in this case, rather than the established cause.  Upper endoscopy would reach minimally into the small intestine, not deep enough to evaluate a jejunal or ileal stricture, and colonoscopy did not find a stenosis that would cause a bowel obstruction.  Wireless capsule endoscopy evaluates the small intestine and has proven useful for detection of occult Crohns disease.  Data from retrospective and prospective studies have shown that capsule endoscopy is useful for the diagnosis of Crohns disease even if imaging tests such as small bowel follow through and ileoscopy are negative or unsuccessful.  The use of a patency capsule  is beneficial in patients with risk for bowel obstruction due to the capsule, as in this case of a patient with prior obstruction.  Final Result: Two reviewers determined that the requested services are likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: All three physician reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology 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: Overturned

Findings:  The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for continued use of a continuous positive airway pressure (CPAP) machine (HCPCS code E0601) and humidifier (HCPCS code E0562). Patil and colleagues strongly recommend the use of CPAP therapy for ongoing treatment of obstructive sleep apnea (OSA) in adults. In this case, the patient has a diagnosis of severe OSA and a history of childhood asthma. The submitted records documented that the patent is compliant with CPAP therapy. Given that OSA is a chronic disease requiring treatment that, left untreated, may exacerbate the patients asthma and cause major health issues such as hypertension, cardiovascular disease, and stroke, the requested equipment is medically indicated. Therefore, continued use of a continuous positive airway pressure (CPAP) machine (HCPCS code E0601) and humidifier (HCPCS code E0562) is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested equipment 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 sub-specialty 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

A 60-year-old male enrollee has requested lipoprotein laboratory testing for evaluation of his medical condition.  Findings:  Two physician reviewers found that in this patients case, the testing at issue was not likely to have been more effective than other methods of evaluation.  At the time of this evaluation, the patient had a documented history of diabetes mellitus, hypertension, and a strong family history of cardiovascular disease.  He was already being appropriately treated with a specific medication, and his fasting lipid profile was within goal parameters.  Therefore, use of the additional lipoprotein analysis would not add any additional clinical information that would change the therapeutic plan.  In sum, lipoprotein laboratory testing is not likely to be of greater benefit than other available diagnostic measures.
Appeal type: Medical Necessity
Decision: Overturned

A 31-year-old male enrollee has requested for continued care by a pain management specialist and therapeutic injection with ultrasound needle guidance to the right sacroiliac joint for treatment of his sacroiliac joint dysfunction, lower back pain and myofascial pain syndrome. Findings:  The physician reviewer found that Boswell and colleagues have written an evidence-based practice guideline. They reported that the sacroiliac joint is accepted as a potential source of low back and/or buttock pain, with or without lower extremity pain. They noted that diagnostic blocks of a sacroiliac joint can be performed to determine whether the sacroiliac joint is the source of the pain. The sacroiliac joint can be anesthetized with intraarticular injection of local anesthetic. The rationale for sacroiliac joint blocks for diagnosis is based upon the fact that sacroiliac joints are innervated and are capable of being a source of low back pain and referred painin the lower extremity. The face validity of sacroiliac joint blocks has been established by injecting small volumes of local anesthetic with contrast into the joint and determining contrast spread in posterior, anterior and lateral radiographs. Construct validity of sacroiliac joint blocks has been established by determining the false-positive rate of single, uncontrolled, sacroiliac joint injections of 20% and 22%. The evidence for the accuracy of sacroiliac joint diagnostic injections is moderate for the diagnosis of sacroiliac joint pain.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for exome sequence analysis. Exome sequencing is a comprehensive test that identifies changes in a patients DNA that are causative or related to their medical concerns. In contrast to current sequencing tests that analyze one gene or small groups of related genes, exome sequencing will analyze the exons or coding regions of over 20,000 genes. Errors occur in DNA sequences causing genetic disorders are located in the exons. Exome sequencing is a diagnostic test with high sensitivity and specificity. Thus, sequencing the exome is an effective method of analyzing a patients DNA to determine the genetic cause of disease or disability. Neurodevelopmental disorders are often complex clinical scenarios attributable to single-gene mutations at more than 1,000 different loci within the genome. In a study found the 119 children affected by neurodevelopmental disorders who underwent exome sequencing, 45% received a molecular diagnoses leading to a change in the clinical care or impression of the pathophysiology. In a retrospective a of, 78 patients with neurodevelopmental disabilities and unrevealing work-up underwent testing with exome sequencing. The results yielded a presumptive diagnostic rate of 41%. In this case, several prior genetic studies have been conducted, all of which failed to reveal a unifying molecular diagnosis to guide treatment and surveillance strategies. The American College of Medical Genetics and Genomics support a role for whole exome sequencing for this patient. Therefore, the requested exome sequence analysis is medically necessary for evaluation of 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 pediatrics with subspecialty certifications in neurodevelopmental behavioral pediatrics and 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 a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 35-year-old female with right leg varices and great saphenous vein (GSV) reflux on duplex exam.  She underwent sclerotherapy in December 2004 and apparently had some relief of her pain symptoms, although she did not have her GSV reflux addressed. Following the sclerotherapy, the patient had some residual pain and later developed scarring and local recurrence of a varicose vein.  The patient seeks authorization for removal of the varicose vein and revision of the scar. The Health Plan denied her request based upon a determination that the procedures are not medically necessary.The patient has a right thigh varix that was treated with sclerotherapy and has now reoccurred along with a scar and recurrent pain. She also has GVS reflux and incompetence that has not been treated.  In this clinical context, the isolated treatment of varices (sclerotherapy or phlebectomy) is not medically appropriate. Because this patients GSV reflux was never addressed, (i.e. venous closure, EVLT, or stripping) it is not a surprise that the varix recurred.  The scar that accompanied the varix is not only unsightly but is also likely to contribute to her lower extremity pain. Until the GSV reflux is addressed, a clear determination as to the source of the patients leg pain cannot be made.  It is not likely that the isolated varix and scar on the right thigh are the only contributing factors. In summary, the request for an isolated varix excision (phlebectomy) and scar revision is not medically necessary or appropriate at this time. If the patient has her GSV reflux addressed and continues to have pain at the site of the varix, phlebectomy may then be appropriate and medically necessary. Based upon the information set forth above, I have determined the requested procedures are not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a two-year-old male enrollee has requested for speech therapy for treatment of the enrollees severe expressive language impairment. Findings:  The physician reviewer found that speech and language development is considered by experts to be a useful indicator of a childs overall development and children with speech and language delays have also shown more behavior problems and impaired psychosocial adjustment (Nelson, et al.). While some children resolve their speech and language delays independently, those who do not may have long-term problems (Law, et al.). Law, et al. indicates that overall, there is a positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulties. Bernhardt and Major also indicate that early phonological and metaphonological intervention can promote normalization of speech development and normal acquisition of literacy skills for at least some children with a history of severe phonological impairment. Finally, in a recent review of therapeutic intervention for children with speech and language delay, the authors concluded that there is good data available to support the effectiveness of speech-language therapy, particularly for children with primary expressive language disorder (McLaughlin). Studies have shown that speech therapy can result in significant improvement in such children. Therefore, it is medically necessary and appropriate to provide speech therapy to this patient.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Xyrem, Wakix, and/or Nuvigil. Findings:  The physician reviewer found that records provided for review document that this patient presents with a history of narcolepsy as demonstrated on polysomnogram followed by a multiple sleep latency test (MSLT). The patient has failed treatment with Vyvanse and Sunosi. The patients provider has recommended combination treatment with Xyrem, Wakix and Nuvigil. Per the American Academy of Sleep Medicine (AASM) guidelines, the requested combination therapy consisting of Xyrem, Wakix, and Nuvigil are appropriate to treat this patients narcolepsy . Xyrem, Wakix, and Nuvigil and each considered first-line medications for the treatment of patients with narcolepsy. Due to the severity of this patients daytime sleepiness, it is reasonable to use these agents in combination. Therefore, the requested Xyrem, Wakix, and Nuvigil are medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested medications are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in internal medicine with subspecialty certifications in preventive medicine, pulmonary diseases, critical care medicine, and 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

A 49-year-old male enrollee has requested total disc arthroplasty (22856) and each additional interspace, cervical (0092T) for evaluation of his cervical spondylosis with myelopathy. Findings:  Three physician reviewers found that total disc arthroplasty (22856) and each additional interspace, cervical is not likely to be more beneficial for treatment of the patients medical condition than any available standard treatment. There is a lack of adequate medical literature that supports disc arthroplasty for the treatment of cervical spondylotic myelopathy. This is particularly true for patients with two level myelomalacia. In addition, a paucity of quality literature exists regarding treatment outcomes associated with arthroplasty for symptomatic cervical spondylotic myelopathy. Comparative prospective studies with long-term follow-up and standardized outcome measures are needed to assess treatment outcomes associated with these alternative techniques appropriately. In sum, the requested procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

A 66-year-old male enrollee has requested Lyrica for the treatment of his peripheral neuropathy. Findings:  The physician reviewer found that the submitted clinical evidence demonstrates that the patient has chronic neuropathic pain with post-laminectomy syndrome, and has needed invasive treatment as well as oral agents for management. He is taking Duragesic, Norco, Neurontin, Lyrica, and Cymbalta. A trial of Lyrica has been beneficial, and when discontinued, led to functional decline. The Health Plan has denied coverage for Lyrica as not medically necessary, and states that the FDA has only approved the drug for post herpetic neuralgia (PHN), diabetic neuropathy pain, and epilepsy. PHN and diabetic neuropathy are often the best studied conditions with new medication for neuropathic pain due to their relatively high prevalence and thus ease of study.  Medications useful for treatment of diabetic polyneuropathy are often useful for treatment of neuropathic pain from other causes. Treatment in this case can reasonably be extrapolated from data and experience with diabetic neuropathy as well as the patients own experience with treatment on a trial basis. Standard treatments for neuropathic pain have been tried and have provided inadequate relief. Lyrica has been beneficial, and therefore should be continued.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: A male enrollee has requested reimbursement and prospective authorization and coverage for residential treatment center (RTC) services. On admission to RTC level of care, the patients withdrawal symptoms were described as mild-to-moderate. He was not a danger to himself or others. He has been able to care for himself. There have been no emotional, behavioral, or cognitive factors prevent him from receiving treatment at a lower level of care. The patient has not reportedly received substance abuse treatment at a lower level of care. Although HIV positive, his viral load was undetectable, and he has been otherwise medically stable. His vital signs have been stable. He has been psychiatrically stable as well, in the sense that his medication management has not required the residential setting for the minimal changes that have been made. He has not demonstrated aberrant behavior, he has not been manic, psychotic, or agitated. He has a supportive family. There have been no barriers to being effectively treated at intensive outpatient program (IOP) level of care. All told, the patient did not and does not require the strict and restrictive setting of 24-hour monitoring at residential level of care. Accordingly, the RTC services provided were not and are not medically necessary for treatment of this patients behavioral health issues. 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 with sub-specialty certification in addiction 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: Overturned

Nature of Statutory Criteria/Case Summary: The enrollee has requested authorization and coverage for bilateral knee Orthovisc injections. The Health Plan denied the request and reported the requested services are not medically necessary for the treatment of this patient. At issue in this case is whether bilateral knee Orthovisc injections are medically necessary for the treatment of the patients medical condition. Review of the current medical literature pertaining to viscosupplementation reveals mixed results.  Although viscosupplementation may relieve knee pain in some patients with osteoarthritis, it is unknown which patients will benefit. Viscosupplementation can only be recommended in patients with a history of lasting benefit from prior injections and in carefully selected cases where the options are limited. A clinical trial found that viscosupplementation increased functional scores in patients with severe osteoarthritis of the knee, especially within three months of injection. In this case, the patient benefitted from prior viscosupplementation. Furthermore, her options are limited. The patient has tried and failed other conservative treatments, with the alternative being a total knee arthroplasty. Medical evidence supports the requested services in this clinical setting. Therefore, bilateral knee Orthovisc injections 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 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: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for tramadol. Findings:  The physician reviewer found that On determining when to initiate or continue opioids for chronic pain, Dowell and colleagues report, Nonpharmacologic therapy and nonopioid pharmacologic therapy are preferred for chronic pain. Clinicians should consider opioid therapy only if expected benefits for both pain and function are anticipated to outweigh risks to the patient. If opioids are used, they should be combined with nonpharmacologic therapy and nonopioid pharmacologic therapy, as appropriate.  The authors further note, Clinicians should evaluate benefits and harms with patients within one to four weeks of starting opioid therapy for chronic pain or of dose escalation. Clinicians should evaluate benefits and harms of continued therapy with patients every three months or more frequently. If benefits do not outweigh harms of continued opioid therapy, clinicians should optimize other therapies and work with patients to taper opioids to lower dosages or to taper and discontinue opioids. The Federation of State Medical Boards (FSMB) states, Continuation, modification or termination of opioid therapy for pain is contingent on the clinicians evaluation of (1) evidence of the patients progress toward treatment objectives and (2) the absence of substantial risks or adverse events, such as signs of substance use disorder and/or diversion. Further, the FSMB strongly recommends prescribers use opioid therapy for chronic pain that is not cancer-related, or part of palliative care or end-of-life care, only when non-opioid and non-pharmacological options have not been effective. Maintain opioid dosage as low as possible and continue only if clear and objective outcomes are being met. In this case, the records indicate that the patient was previously prescribed tramadol in 2019. Her diagnoses included chronic joint pain and fibromyalgia. The submitted records did not include documentation from the patients provider recommending or prescribing tramadol. There was also no evidence that the appropriate opioid compliance monitoring has taken place such as a check of the California Controlled Substances and Utilization Review Evaluation System (CURES) or evidence of a baseline urine drug screen. Therefore, Tramadol 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 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: Upheld

A 44-year-old female enrollee requested authorization and coverage for treatment with interferon gamma-1b.  The health plan has denied this request indicating that the requested treatment is considered experimental for treatment of the enrollees severe pulmonary fibrosis.Three physician reviewers performed an experimental/investigational Independent Medical Review.  Because two of the three physician reviewers concluded that the requested therapy is not likely to be more beneficial for treatment of your medical condition than any available standard therapy, the Health Plans denial has been upheld.