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

A 47-year-old male enrollee has requested discectomy and decompression for treatment of his disc herniation at L4-5.    Findings:  The physician reviewer found that radiculopathy is defined as significant alteration in the function of a nerve root. The most important clinical components required to support the diagnosis of a radiculopathy include: 1) subjective complaint of pain, numbness, and/or paresthesias in a spinal nerve distribution and 2) associated clinical findings such as loss of related reflexes, muscle weakness and/or atrophy of muscle groups in the related myotome, altered sensation in the corresponding dermatome(s) or positive nerve root tension signs (straight leg raise, femoral nerve stretch tests, brachial plexus tension tests) resulting in provocation of radicular pain. The patient in this particular case had subjective symptoms of an L5 radiculopathy, but no objective clinical findings such as weakness, numbness or reflex abnormalities. The MRI and CT did show evidence of L5 nerve root compression from a paracentral disc herniation, but the operation performed was an L4-L5 transpedicular approach for disc removal. Such an operation is only indicated for far lateral disc herniation and in this case, such a herniation would cause compression of the L4 nerve root. Since there is no subjective, objective clinical or radiographic evidence of L4 radiculopathy or nerve root compression, the surgery at issue was not medically indicated or necessary.
Appeal type: Medical Necessity
Decision: Upheld

A 46-year-old female enrollee has requested coverage for spine surgery for treatment of the enrollees neck pain and arm pain. Findings:  The physician reviewer found that anterior cervical decompression and fusion may improve cervical radicular symptoms in patients who have pain and loss of strength and sensation who have not responded to conservative management.  Many patients with cervical spondylotic myelopathy respond to conservative treatment, especially those with mild signs.  However, there is a lack of evidence in the medical literature supporting surgery, as opposed to conservative management, with regard to long-term benefits for patients with degenerative radiculopathy or myelopathy.  At this time, further large-scale randomized trials are needed.  In this patients case, there is a paucity of documentation to support the diagnoses of myelopathy and radiculopathy.  The electromyography/nerve conduction velocity studies do not indicate the presence of an acute process.  The reports of the CT scans do not document the presence of an anatomic change over time.  The providers report of an MRI showing a large herniation at C5-6 is not accompanied by reports of neurologic findings on examination.  There is a lack of documentation of any conservative care since the initial surgical procedure.  All told, the requested spine surgery is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

A 31-year-old male enrollee requested authorization and coverage of a gastric bypass surgery consultation. The Health Plan denied the request indicating that the requested consultation is not medically necessary for evaluation of the enrollees morbid obesity.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plans denial on the basis that the requested consultation is medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollees parent has requested authorization and coverage for sublingual immunotherapy and/or food tolerance induction. The records provided for review document that this patient has a history of food allergies for which his provider has recommended oral immunotherapy. However, there is a lack of published peer-reviewed literature, scientific evidence, or professional standard guidelines supporting the safety and efficacy of food allergy oral immunotherapy. The newly available, U.S. Food and Drug Administration (FDA) approved oral immunotherapy treatment Palforzia, was not included in the treatment plan for this patient, who has a diagnosis of allergy to peanut. With the exception of Palforzia, there are no other FDA-approved oral immunotherapy/desensitization treatments available. Current standard food allergy guidelines and recommendations for food allergy still include avoidance and the availability of an epinephrine autoinjector. Per the American Academy of Allergy, Asthma, and Immunology (AAAAI), oral immunotherapy (OIT) is not a curative therapy and patients who undergo treatment with OIT need to continue to carry epinephrine and avoid allergens. Per the AAAAI, it is not expected that OIT will lead to ingestion of the allergen without limitation. The current standard of care for treatment of food allergy is avoidance of the allergen and treatment of anaphylaxis with auto-injectable epinephrine. For these reasons, the requested sublingual immunotherapy and/or food tolerance induction is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Findings:  Three of the three physician reviewers found the requested sublingual immunotherapy and/or food tolerance induction is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The 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: Physician reviewer 1 is board certified in internal medicine with subspecialty certification in allergy and  immunology and is actively practicing. Physician reviewer 2 is board certified in allergy and  immunology and is actively practicing. Physician reviewer 3 is board certified in allergy and  immunology with subspecialty certification in pediatrics and is 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: Upheld

A 26-year-old female enrollee has requested for CT lumbar and thoracic spine for evaluation of her back pain. Findings:  The physician reviewer found that one of the difficulties with advanced imaging studies (CT and MRI) is that abnormal findings are found in asymptomatic patients.  In regards to this patient, her clinical picture is consistent with uncomplicated back pain, as there are no neurological symptoms or findings, and there is no clinical concern of infection or cancer.  There is also no history of recent significant trauma.  The patient does not have any of the red flags listed above.  The patient has not had a trial of conservative therapy for four to six weeks.  If the patients symptoms do not improve or worsen with conservative therapy, then advanced imaging (CT or MRI) may be indicated.
Appeal type: Medical Necessity
Decision: Upheld

A 58-year-old male enrollee requested a magnetic resonance imaging (MRI) for medical evaluation of his low back pain and right leg weakness. Findings:  The physician reviewer found that based on the available medical records, there is no noted sign or symptom to support the requested lumbar MRI as medically necessary. Applying the guidelines from the National Imaging Associates (NIA) and American College of Radiology (ACR), there are no red flags providing an immediate indication for imaging of the lumbar spine. Such red flags would include fever and possible infection, tumor, abnormal reflex or extremity weakness. All told, the requested MRI of the lumbar spine is not medically necessary for evaluation of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested three-dimensional (3D) breast tomosynthesis for evaluation of her medical condition.  Findings:  Two physician reviewers found that the American College of Radiology (ACR) statement on breast tomosynthesis has urged the technique be removed from the investigational category due to the advantages this new technique brings to radiologists in the interpretation of mammograms. The advantages the technique offers relates to the tomographic nature of tomosynthesis which helps radiologists differentiate dense glandular tissue from architectural distortion which in turn decreases callbacks and increases detection of small cancers. For these reasons, the addition of tomosynthesis to the usual two-dimensional (2D) images was likely of more benefit to the patient than had the exam been done with 2D technique only. In sum, 3D breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: Two reviewers determined that the services at issue were 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 reviewers are board certified in diagnostic radiology and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Epclusa for 12 weeks. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees hepatitis C virus.According to the  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. The guidelines recommend that all patients should be treated, regardless of fibrosis stage. The guidelines recommend that non-cirrhotic treatment naive  patients should be treated , based on a 98% cure rate in the  guidelines cite data showing reduced survival with delayed treatment For these reasons, Epclusa for 12 weeks is supported as medically necessary for the treatment of this patients hepatitis C infection.Final Result: The reviewer determined that 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 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. Findings:  The physician reviewer found that
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 mental and substance abuse residential treatment services provided from the date of service in question, forward.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  The records do not document suicidal or homicidal ideation or psychosis during the dates in dispute.  She had continued symptoms of depression and had not engaged in any self-harm behaviors. She was not displaying significant or severe behavioral problems while in the residential treatment center.  The records indicate that this patient needs additional treatment to further improve her social functioning, mood and behaviors.  However, per the records, she no longer needs the restrictiveness of a residential treatment facility, as she has stabilized enough to transition to a less restrictive setting.  Outpatient treatment and least restrictive options are considered first lines of care.  There are benefits to in-home therapy due to the involvement with family as well as generalization of learned skills in a natural setting.  All told, mental and substance abuse residential treatment services provided from the date of service in question, forward were not and are not medically indicated for the treatment of this patient. Final Result: The reviewer determined that the services at issue were not and are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The 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: Overturned

The patient is a 76-year-old female who has been diagnosed with severe degenerative arthritis of the right knee and left knee. On 8/19/16, the records noted that a right knee cortisone injection was administered on 7/27/16, with minimal pain relief. The patient has also been treated with physical therapy and medications, including Tylenol, Naprosyn, and ibuprofen. On 2/26/19, the provider noted an x-ray of the left knee revealed evidence of severe degenerative arthritis of the patellofemoral joint. On 4/24/19, the patient reported that her knees were tender and sore. A left knee steroid injection was administered. The provider noted a Synvisc injection and knee replacement were considered. On 5/29/19, the provider prescribed a Synvisc One injection for the left knee. In an application for independent medical review dated 7/9/19, the patient reported receiving a Synvisc One injection in the right knee two-and-a-half years ago, and this was beneficial. The patient has requested authorization and coverage for a Synvisc One injection to the left knee. 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 a Synvisc One injection to the left knee is 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. The physician reviewer found that 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 by Campos and colleagues found that viscosupplementation increased functional scores in patients with severe osteoarthritis of the knee, especially within three months of injection. In this case, the patients options are limited. The patient has tried and failed other conservative treatments, including a corticosteroid injection, with the alternative being a total knee arthroplasty. Furthermore, she benefitted from a viscosupplementation injection of her right knee in the past. The medical evidence supports the requested service in this clinical setting. Therefore, a Synvisc One injection to the left knee is medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

A 45-year-old female enrollee has requested authorization and coverage for the medication Lyrica for treatment of her fibromyalgia.  Findings:  The physician reviewer found that per the submitted medical history, the patient has pain due to fibromyalgia and rheumatoid arthritis. She does not have neuropathic pain or diabetes. Lyrica has not been well-studied or proven effective or medically appropriate for fibromyalgia and rheumatoid arthritis.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for biofeedback therapy. The Health Plan has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees pelvic floor dysfunction. The submitted documentation supports the requested services in this patients case. Research indicated that biofeedback therapy is effective in the long term management of patients with chronic constipation and dyssynergic defection and is more likely to restore normal bowel function than standard therapy with laxatives. This therapy is well accepted, and has a high rate of success in improving bowel function and helping patients avoid surgery. It is particularly helpful in pelvic dyssynergia. The proposed biofeedback therapy has been shown to be more effective than laxatives. The only other alternative is surgical treatment, which is associated with significant morbidity, and could potentially be avoided with biofeedback therapy. Therefore, the requested biofeedback therapy is 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 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: Experimental/Investigational
Decision: Upheld

A 51-year-old male enrollee has requested perispinal injections (etanercept) for treatment of his back pain.  Findings:  Three physician reviewers found that there is a paucity of peer-reviewed literature supporting etanercept injections for the medical condition in question. There is a lack of high-quality, double-blinded, controlled trials supporting the efficacy of these services.  Cohen and colleagues performed a double-blind, placebo-controlled pilot study to evaluate intradiscal etanercept in patients with chronic discogenic low back pain or lumbosacral radiculopathy. They found no differences in pain scores or disability scores between or within groups for any dose range or subgroup of patients.  Genevay and colleagues conducted a pilot study to explore the efficacy of etanercept in patients with severe sciatica. They observed that the patients within this group had sustained improvement after a short treatment with etanercept that was better than standard care plus a short course of methylprednisolone. They concluded that the results suggest that etanercept is beneficial in the treatment of sciatica and support a pathological role for TNF-alpha in the pathogenesis of sciatica. However, they indicated that their results need to be confirmed by a randomized controlled trial.Tobinick and Davoodfar performed a retrospective clinical review of patients treated with etanercept for back and neck pain at a single private medical clinic in 2003. The review concluded that perispinal etanercept can lead to significant clinical improvement in selected patients with chronic, treatment-refractory, disc-related pain. They noted, however, that generalizability of the study results is limited by the open-label uncontrolled methodology employed. The review concluded that further study of perispinal etanercept injections utilizing double-blind, placebo-controlled methodology is indicated.  In sum, the etanercept injections provided on the date in question were not likely to have been more beneficial than other available treatments in this patients case.
Appeal type: Medical Necessity
Decision: Upheld

A 41-year-old female enrollee has requested cervical radiofrequency facet joint ablations and medial branch blocks for treatment of her neck and bilateral shoulder pain.  Findings:  The physician reviewer found that this patient has recently undergone several cervical spine interventions and her treating physician has not recommended additional blocks/ablation procedures at this time. If it is documented by the patients physician that the previous techniques are no longer providing adequate relief or that untreated levels have failed to respond to conservative therapies, additional spinal procedures may then be indicated. At that time, cervical medial branch blocks may be appropriate to determine prognosticate response.  Sehgal, et al. reported that medial branch blocks are employed to diagnose facet joint pain because available techniques cannot identify the pain generating structure in patients with chronic spinal pain. The authors performed a literature review of clinical studies on efficacy and utility of facet joint blocks in diagnosing facet joint pain. From the evidence obtained, they concluded that controlled comparative local anesthetic blocks of facet joints (medial branch or dorsal ramus) are reproducible, reasonably accurate, and safe. Thus, cervical medial branch blocks are performed to determine potential response to therapeutic facet joint interventions such as radiofrequency ablations. Cervical facet joint ablations are not medically necessary if cervical medial branch blocks have not been performed prior to ablation procedures. Therefore, if objective documentation from the patients physician is provided which indicates that the patients cervical spine pain is no longer responding to prior/conservative measures, then cervical medial branch blocks may be medically necessary prior to cervical facet radiofrequency ablation and the patients request should be reconsidered at that time. However, cervical facet radiofrequency ablation is not appropriate without documentation of response to diagnostic blocks.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for weekly eye movement desensitization and reprocessing (EMDR) therapy for one year. The records provided for review document that this patient is now halfway through her high-risk pregnancy with her second child. As per the clinical documentation, the patients first delivery was traumatic with retained placenta and severe hemorrhage. The patient has been diagnosed with post-traumatic stress disorder (PTSD) and she is being triggered daily due to the impending delivery of her second child. Based on the patients current presentation, diagnosis, and history, the requested weekly individual psychotherapy with EMDR for trauma is indicated to stabilize her psychiatrically and medically during this pregnancy. EMDR will assist in transitioning the patient to delivery of this child as well as provide support in the postpartum phase. However, there is a lack of support for the provision of EMDR therapy for one year. EMDR is generally administered over six to 12 sessions over approximately 90 days. Re-evaluation of the patient at that time would be indicated to determine if additional EMDR therapy is medically necessary. For these reasons, weekly EMDR therapy for 90 days is medically necessary for treatment of this patient.Final Result: The reviewer determined that a portion of the requested services is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned. Credentials/Qualifications: The reviewer is board certified in psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.