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

Nature of Statutory Criteria/Case Summary:  The enrollee has requested reimbursement for a home sleep study. Based on the records, the enrollee underwent a neurology consultation for complaints of possible Obstructive Sleep Apnea (OSA). Her past medical history included migraine headaches and chronic sinus infections. Her chief complaint was trouble sleeping at night for 20 years and she complained of being sleepy all day, teeth grinding and snoring.  She had broken several night mouth guards as a result.  The enrollee also had a sinuplasty and septoplasty but the sleeping and snoring did not improve. Her total amount of sleep per night was 5 to 6 hours.  The record indicated no restlessness, tingling or crawling in her arms and legs and she did not experience an inability to keep her legs still prior to falling asleep.  The enrollees provider indicated the enrollee had many symptoms consistent with OSA and was to undergo a diagnostic sleep study. According to the medical literature, the two accepted methods of objective testing for patients suspected to have obstructive sleep apnea (OSA) are an in-laboratory polysomnography and home testing with portable monitors. Specifically, polysomnography is recommended for the diagnosis of all sleep-related breathing disorders to include OSA. An attended, in-laboratory polysomnography is performed rather than home testing, in patients with suspected complicated OSA, such as in enrollees with cardiorespiratory disease or narcolepsy. Home sleep apnea testing may be used for the diagnosis of OSA in enrollees with a high pre-test probability of moderate to severe uncomplicated OSA, such as in enrollees without medical co-morbidities. According to the sleep study report, this enrollee had an elevated Epworth Sleepiness Scale (ESS) score of 13. The records also indicate she has a diagnosis of hypersomnia. It was not noted to be idiopathic hypersomnia, and she had no major co-morbidities. However, the enrollee did have a high pre-test probability of moderate to severe uncomplicated OSA as indicated by her ESS. Therefore, the home sleep study performed was medically necessary to treat the enrollees condition.Final Result: The reviewer determined that the service at issue is medically necessary for treatment of the enrollees condition. Credentials/Qualifications: The physician reviewer is board certified 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 similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

A 63-year-old female enrollee has requested biofeedback for treatment of her fecal incontinence. Findings:  Two physician reviewers found that although there are no large-scale, randomized trials on the treatment of incontinence with biofeedback, the therapy is well accepted as an effective therapy by the gastroenterology community. A study by Ozlurk and colleagues found that biofeedback therapy produced sustained improvement in bowel symptoms and anorectal function. The authors noted that biofeedback is safer than surgical interventions, and given its efficacy, it should be offered to incontinent patients unresponsive to medical therapy. In this patients case, she has had prior sessions of biofeedback which were effective. As such, biofeedback is likely to be the most efficacious treatment alternative in this case. The patient has benefitted from this therapy in the past, and with properly motivated patients, good outcomes are seen.
Appeal type: Medical Necessity
Decision: Upheld

A 35-year-old female enrollee requested a laparoscopic hysterectomy for medical treatment of the enrollees pelvic pain and menorrhagia.  Findings:  The physician reviewer found that there is no indication for any surgery at this time based on her cervical issues.  This patient underwent endometrial ablation previously, and the records following the procedure noted that the patient was doing well.  The current medical evidence does not support laparoscopic hysterectomy in this clinical setting.  It is likely that this patients symptoms will respond to endometrial ablation, and if her symptoms do not resolve, there are other options for management prior to proceeding with hysterectomy.  All told, the requested laparoscopic hysterectomy is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a four-year-old male has requested six hours per week of social skills training in a group setting for treatment of his autism.  Findings:  The physician reviewer found that the submitted documentation demonstrates the patient is making progress within the treatment parameters of his ABA therapy. While the patients therapists report gains in his social skills, they have recommended additional social skills training in a group setting. As a preschooler who is developmentally challenged, the patient is not likely to benefit from participation in a mainstream verbal preschool program. Although there is limited literature studying the effectiveness of formal social skills groups for a preschool child, a study by Rohlander and colleagues points out that the most direct way to introduce an autistic child to social skills is for the child to participate in a social skills group. In a review by Reichow and colleagues, the authors performed a meta-analysis of the available data regarding the value of social skills groups for autistic children. While there was a limited number of studies available to review, the authors concluded there was positive evidence that social skills groups do improve social competence in autistic children. All told, there is sufficient evidence in this case to support the medical necessity of the requested six hours per week of social skills training in a group setting.
Appeal type: Experimental/Investigational
Decision: Upheld

A 43-year-old female enrollee has requested authorization and coverage for radiofrequency neurolysis. The Health Plan has denied this request indicating that the requested procedure is considered investigational for treatment of the enrollees neck pain.  Findings:  Two physician reviewers found that cervical medial branch radiofrequency neurotomy is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The majority of peer-reviewed literature supports the efficacy of radiofrequency neurotomy in the treatment of chronic spinal pain due to facet pathology as long as the patients are appropriately selected.  In reviewing the submitted medical records, this patient has had a spinal fusion in the area to be treated with radiofrequency ablation. The medical literature does not support the efficacy of radiofrequency ablation at levels in which the medial/lateral branches are already disrupted, that is, have been treated with spinal fusion.  This patient had two cervical spinal fusions. If there is disruption of the cervical medial branches, then there is nothing to ablate and it is less likely the patient will benefit from cervical medial branch radiofrequency. Further, a study by Cohen, et al. proposed that cervical facet denervation was less likely to be beneficial due to poor selection criteria. One of the variables affecting outcomes was prior surgery and the levels treated. Dreyfuss, et al. performed a prospective audit to establish the efficacy of medial branch neurotomy under optimum conditions. They determined that medial branch neurotomy is an effective means of reducing pain in patients carefully selected on the basis of controlled diagnostic blocks. They also determined that adequate coagulation of the target nerves can be achieved by carefully placing the electrode in correct position as judged radiologically. If the anatomy were disrupted as possible in spinal fusion, it would be difficult to adequately coagulate targeted nerves if they are still present.
Appeal type: Medical Necessity
Decision: Upheld

A 39-year-old female enrollee requested authorization and coverage of laser treatment post scar revision. The Health Plan denied the request indicating that the requested therapy is considered cosmetic in nature and not medically necessary for treatment of the enrollees suprapubic scar.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested therapy is cosmetic in nature and not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of the patient requested authorization and coverage of Aimovig 140 mg/mL auto-injector. A study describes erenumab as a monoclonal antibody against calcitonin gene-related peptide (CGRP) or its receptor that offers considerable improvements in migraine prophylaxis and is designed to act on the trigeminal pain system. Researchers reviewed  recommendations on the use of anti-CGRP monoclonal antibodies in children and adolescents with severe, refractory migraine. The researchers recommended an initial trial of anti-CGRP at the lowest available dose, and a higher dose if no improvement was seen. In this case, the patient had daily severe chronic migraines and a PedMIDAS score of 95, indicating severe disability. The patient had tried and failed several preventive treatments. Since starting Aimovig, the patient has reported improvement. Given the current medical literature and the providers recommendation to increase the patient's dosage to further increase the therapeutic effect, the requested dosage of the medication is medically indicated. Therefore, Aimovig 140 mg/mL auto-injector is medically necessary for the 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 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

A 50-year-old male enrollee has requested computed tomography (CT) of the abdomen and pelvis and sacroiliac joint injections for treatment of his lumbago and epigastric pain.  Findings:  The physician reviewer found that the requested CT of the abdomen and pelvis and sacroiliac joint injections are not medically necessary for evaluation and treatment of this patients medical condition. The patient had a normal blood test and urine test. Therefore, there is no indication for a CT scan of the abdomen and pelvis. Additionally, the patient describes low back pain characteristic of lumbar radiculitis from a nerve root irritation. The physical examination and patient subjective symptoms do not indicate sacroiliac joint dysfunction. A sacroiliac joint injection is also not medically necessary.Dreyfuss and colleagues suggested that diagnosing sacroiliac joint mediated pain is difficult because the presenting complaints were similar to other causes of back pain. The authors noted that radiographic and laboratory tests primarily help exclude other sources of low back pain while MRI, CT, and bone scans of the sacroiliac joint cannot reliably determine whether the joint is the source of the pain. The authors concluded that, controlled analgesic injections of the sacroiliac joint are the most important tool in the diagnosis. Zelle and colleagues assessed the clinical presentation, diagnostic testing and treatment options for sacroiliac joint dysfunction via a systematic literature review. They found that a reliable examination technique to identify the sacroiliac joint as a source of low back pain seems to be relief of pain following a radiological guided injection of local anesthetic into the sacroiliac joint. However, the current literature does not include generally accepted guidelines for the diagnosis and treatment of sacroiliac instability. All told, the requested CT of the abdomen and pelvis, and sacroiliac joint injections, are not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for computed tomography (CT) scan of the lower extremity without contrast material and/or magnetic resonance imaging (MRI) of any joint of lower extremity. Findings:  The physician reviewer found that The records provided for review document that this patient sustained a right talus fracture in a fall from a ladder. The patients provider has recommended treatment with surgery. As part of the patients preoperative evaluation, the provider has recommended right lower extremity imaging with MRI and CT scans. Barnett and colleagues noted that talus fractures can have devastating consequences. The authors reported that, The blood supply to the talus is tenuous and injuries are associated with a higher incidence of avascular necrosis and malunion. The talus involves multirotational movement, and in this patients case, involves multiple small fragments. As noted by the patients provider, the ultimate treatment often involves a joint fusion. As part of the patients preoperative work-up, the requested CT and MRI of the lower extremity are medically necessary. The current status of the patients condition including location of multiple fragments, which may have partially healed or moved, need to be assessed with a current CT scan prior to surgery. The patients previous CT scan was performed about nine months ago. Dale and colleagues determined that additional fracture information on talus fractures was not demonstrated on initial x-rays in 93% of cases. Further complicating the patients condition is the likelihood of injury to the ligaments and tendons. The requested lower extremity MRI is the best modality to evaluate these soft tissue injuries. MRI scanning is not routinely used in the early stage but is recommended when patients continue to complain of symptoms four to six weeks following injury in the presence of normal radiographs. Avascular necrosis, in particular, is a significant abnormality effectively diagnosed with an MRI scan. Given these findings, the requested CT scan of the lower extremity without contrast material and MRI of any joint of lower extremity are 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 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: Experimental/Investigational
Decision: Upheld

A 58-year-old male enrollee has requested transoral incisionless fundoplication for treatment of his gastroesophageal reflux disease. Findings: Two physician reviewers found the requested procedure is not likely to be more effective than other available treatment options. The current medical evidence has not established the superior efficacy of the requested transoral incisionless fundoplication. Cadiere, et al. was an open-label study involving 14 patients, and the study by Velanovich involved 26 patients. In about 10% of cases, the device could not be used for technical reasons. The study by Velanovich also reported one major complication. Velanovich recently reported, Since presentation of the series at the Central Surgical Association in March 2010, and subsequent acceptance for publication in Surgery, I have had 2 patients with recurrence of pathologic gastroesophageal reflux and clear failure of their endoscopic, endoluminal fundoplication. One patient recurred 18 months after the initial repair and another 5 months after the initial repair. Both patients had pathologic reflux as documented by 24-hour esophageal pH monitoring. Both patients underwent laparoscopic Nissen fundoplication, which documented that the H-fasteners had pulled through the esophagus and were attached to the gastric fundus. Both recovered uneventfully. Thus, I continue to find that there is insufficient evidence in the peer-reviewed literature demonstrating that transoral incisionless fundoplication is likely to be a superior treatment option for this patients condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested Sovaldi and ribavirin for 12 weeks for treatment of his hepatitis C. Findings:  The physician reviewer found that according to the most recent 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 limited life expectancy due to non-liver-related conditions.  This applies regardless of fibrosis stage or viral load.  Per the guidelines, genotype 2 patients who have failed peg-interferon and ribavirin should be treated with daily Sovaldi and weight-based ribavirin for 16 weeks or 24 weeks.  These guideline recommendations are based on multiple randomized clinical trials.  The FUSION trial demonstrated higher cure rate with 16 weeks of treatment rather than 12 weeks in treatment-experienced patients.  For these reasons, the requested treatment with Sovaldi and ribavirin for 12 weeks is not supported as medically necessary for the treatment of this patients hepatitis C infection.  Final Result: The reviewer determined that I have determined that the requested medications 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 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for repository corticotropin injection (H.P. Acthar Gel). Findings:  The physician reviewer found that review of the submitted documentation and relevant literature demonstrates the medical necessity for the requested medication. H.P. Acthar Gel is U.S. Food and Drug Administration (FDA) approved for treatment of nephrotic syndrome. In this case, the patient has failed treatment with steroids, cyclosporine, and rituximab. Given the patients preserved renal function and ongoing nephrosis, treatment with H.P. Acthar Gel is clinically indicated. As such, the request for repository corticotropin injection (H.P. Acthar Gel) is medically necessary for treatment of the patients medical condition. 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 sub-specialty certification in nephrology 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 parent of an enrollee has requested reimbursement for mental health inpatient treatment for treatment of the enrollees behavioral health conditions.Findings:  The physician reviewer found that the patient met the criteria for treatment at the partial hospitalization program level of care.  The patient required a near-daily structured program to promote progress through the stages of change because of poor treatment engagement, which is consistent with partial hospitalization program level of care.  The records do not demonstrate the need for mental health inpatient treatment during the dates of services at issue.  Based on the medical records, he could have been safely treated at a lower level of care.  Final Result: The reviewer determined that the services at issue were not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The physician reviewer is board certified in psychiatry with sub-specialty certification in child and adolescent 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: An enrollee has requested authorization and coverage for One Touch Verio test strips for treatment of the enrollees type 2 diabetes. Findings:  The physician reviewer found that self-monitoring of blood glucose is an important component of modern therapy for diabetes which has been recommended for diabetic patients in order to improve their glycemic control and to prevent hypoglycemia.  There are numerous glucose monitors which are available for personal use at the present time. The U.S. Food and Drug Administration (FDA) requires that manufacturers demonstrate that their test system provides acceptable accuracy and consistency of results. While the OneTouch Verio is a reliable meter, there are other meters which are available which are of equal reliability.  It is medically appropriate that the patient use a meter which is preferred by the Health Plan.  All told, the requested OneTouch Verio test strips are not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested equipment is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The physician reviewer is board certified in internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism 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.