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

Nature of Statutory Criteria/Case Summary: The parent of a patient has requested reimbursement for a DOC band helmet for treatment of the enrollees severe plagiocephaly and torticollis. Findings:  The physician reviewer found that cranial orthoses may be considered for patients with post cranial vault remodeling surgery for synostosis, moderate to severe non-synostotic plagiocephaly or brachycephaly when the patient is at least three months but not greater than 18 months of age with documented trial of conservative treatment, documentation of cranial asymmetry demonstrated by skull base asymmetry greater than or equal to 6 mm, cranial vault asymmetry greater than or equal to 6 mm, orbitotragial depth asymmetry greater than or equal to 6 mm, and a cephalic index/ratio two standard deviations above or below the mean for gender and age. The initial Star helmet provided to this patient was not appropriate to the patients medical needs for correction of her plagiocephaly. A DOC band was specifically recommended by her treating neurosurgeon. Appropriately fitted cranial molding helmets have been demonstrated to be effective at correcting the skull deformity in infants with positional plagiocephaly. Final Result: The reviewer determined that the device at issue was 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 pediatrics 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

The parent of a 19-month-old male enrollee has requested speech and language therapy one hour per week for treatment of his language delay. 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 cognitive ability. Identification of children at risk for developmental delay or related problems may lead to intervention services and family assistance at a young age when chances for improvement are best. Left untreated speech and language delay in preschool children has shown variable persistence rates. Language delayed children have also shown more behavior problems and impaired psychosocial adjustment. (Nelson, et al) From this detailed account, the long-term consequences of speech and language delay may be substantial. According to a Cochrane Database meta-analysis of 25 studies, there is a positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulties. (Law, et al) In addition, Bernhardt and Major concluded the results of their study suggest 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. In this case, the patient is a young child with significant speech and language delay, particularly in the area of language expression. The etiology of his delays is not completely clear, but may be related to the prenatal complications, intrauterine growth retardation, and severe anemia. Regardless of the etiology, his speech and language deficits negatively impact his ability to interact with others and communicate effectively. Studies have shown that speech and language therapy can result in significant improvement in such patients. It is therefore medically necessary to provide speech and language therapy for this patient.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for bilateral gonadal vein embolization.Findings:  Two of three physician reviewers found that this patient had clinical findings and imaging studies suggestive of pelvic congestion syndrome with vulvar varices. Gonadal vein embolization is an appropriately accepted practice in the medical community. Case reports have shown the benefit of this procedure. As in this case, when vulvar varices are present, the medical evidence shows that treatment of ovarian vein reflux leads to reduction in the size of vulvar varicosities.  Gonadal vein embolization is safe, well-tolerated, and allows for a minimally invasive approach. Therefore, bilateral gonadal vein embolization was likely to have been superior over other available treatment options. Final Result: The reviewers determined that the services at issue were likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in obstetrics and gynecology 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: Upheld

The patient has requested authorization and coverage for Percocet 10 mg #20 every two months. The use of opioid medication is not recommended for the treatment of migraines due to their addictive nature and tendency for causing rebound headaches. There are currently multiple medications available for the prophylactic and abortive treatment of migraines. As per the guidance of the American Headache Society and the American Academy of Neurology, opioids should only be used for the treatment of migraines as a last resort after the patient has failed non-opioid treatment measures. The use of opioids in patients with migraine carries a high risk of medication overuse headache. All told, Percocet 10 mg #20 every two months is not medically necessary for 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 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 magnetic resonance imaging (MRI) of the thoracic spine for the evaluation of her medical condition. There is sufficient support for the requested services in this clinical setting.  In the setting of low back pain in which the patient is a candidate for surgery or other intervention, MRI is the most appropriate imaging modality.  In general, plain x-rays are often of very limited value.  Plain x-rays serve to evaluate the patient for significant structural abnormalities such as fractures, malalignments, and congenital anomalies.  However, plain x-rays are not likely to be beneficial for evaluating patients for a cause for radiculopathy.  In this case, the patient is apparently being considered for surgery. The fact that the patient is developing a radiculopathy and possible nerve compromise is further indication for more intensive evaluation.  All told, the requested MRI of the thoracic spine is medically indicated for the treatment 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 30-year-old male enrollee has requested total disc arthroplasty (artificial disc) for treatment of his back pain. Findings:  Three physician reviewers found that the scientific evidence demonstrates that there is a lack of large, scientific studies showing the long-term safety and efficacy of artificial disc replacement. While the FDA has approved artificial disc implants for marketing, the approval is contingent upon the performance of 5-year, 7-year and 10-year studies to determine the long-term safety and efficacy of these devices. At this time, these studies are still ongoing. Until longer-term results are available, the superiority of artificial disc replacement as compared to conventional modalities remains unproven in this setting.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for platelet rich plasma (PRP) injections. There is a lack of evidence in current medical literature supporting the use of PRP in meniscal repair. In an evaluation specifically addressing the effect of PRP augmentation after meniscal surgery, Griffin and colleagues concluded that no difference in outcomes were seen with the use of PRP augmented meniscal repair. Pourcho and colleagues report that future investigations and high-quality randomized controlled trials are needed to optimize PRP treatment methods. Therefore, PRP injections were not and are not likely to be more beneficial for treatment of the patients condition than any available standard therapy.Findings:  Two of the three physician reviewers found the PRP injections at issue were not and are 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 services at issue were not and 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 reviewers 1, 2, and 3 are board certified in orthopedic surgery and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:   An enrollee has requested inpatient hospitalization services for treatment of the enrollees medical condition.  The physician reviewer found that the submitted documentation supports the medical necessity of the services at issue.  This patient was admitted for continued pain after surgical treatment of a bowel obstruction.  She had an exploratory laparotomy with lysis of adhesions and repair of small bowel serosal tears.  The patient was managed with total parenteral nutrition, a pain pump, and a heparin drip.  Subsequently, the patient was tolerating a full liquid diet, oral pain medications and was changed to Lovenox from heparin.  It was medically reasonable to continue the hospitalization until the patient was controlled with oral pain medication, a full liquid diet and Lovenox for her embolism.  All told, inpatient hospitalization services were medically indicated for the treatment of this patient. Final Result: The reviewer determined that the services at issue were 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 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

The parent of a 15-year-old male enrollee has requested neuro/biofeedback for the treatment of the enrollees attention-deficit hyperactivity disorder (ADHD). Findings:  Three physician reviewers found that neuro/biofeedback is not generally considered an appropriate treatment for ADHD within the psychiatric community. At best, it remains an investigational approach and should only be considered when all available standard and accepted therapies have clearly been shown to fail. That is not the case in this instance according to the record. In fact, it does not appear that any of the established treatments for ADHD were attempted.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for hydrocodone-acetaminophen 10-325 tablets four times per day for treatment of his back pain. Findings:  The physician reviewer found that the step wise World Health Organization (WHO) ladder for pain relief is considered the reasonable approach to pain control in the palliative and the non-palliative setting. However, in this case the records do not demonstrate a thorough work-up for the patients back pain has been completed. In the documentation available for review, the MRI was not entirely normal and it is possible that further work-up will lead to a treatable solution. In addition, not all non-opioid treatment options have been utilized. There is no documentation of behavior therapy despite much research to support its use. Also, not all non-opioid medications classes and physical therapy have been optimized. Moreover, it is reasonable to consider alternatives to opioids. 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 anesthesiology with sub-specialty certification in pain medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

A 48-year-old female enrollee requested sleeve gastrectomy for medical treatment of her morbid obesity.  Findings:  Two physician reviewers found that according to the documentation submitted for review, this patient met the criteria for bariatric surgery based on generally accepted criteria according to the National Institutes of Health (NIH) and American Society for Metabolic and Bariatric Surgery (ASMBS) guidelines.  The sleeve gastrectomy is the standard primary treatment for morbid obesity and was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:   The parent of an enrollee has requested physical therapy for treatment of the enrollees progressive joint stiffening and contractures secondary to Niemann-Pick disease. Findings:  The physician reviewer found that in this clinical setting, the requested services of physical therapy are not medically necessary for treatment of this patients medical condition. The submitted medical records fail to show the need for physical therapy performed by a skilled physical therapist versus continued exercise by a non-skilled health care worker or lay person.   Niemann-Pick disease type B is a condition that affects many body systems and has a wide range of symptoms that vary in severity. While the patient is noted to have joint stiffness due to his disease process, the most recent physical examination provided for review does not show that the patient has any functional deficits that would require physical therapy treatment at this time. The need for physical therapy treatment for this patient is not supported. Given the above, the requested services are not medically necessary.  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 physical medicine and rehabilitation with sub-specialty certification in pediatric rehabilitation 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: An enrollee has requested authorization and coverage for a facet joint injection procedure (CPT 64493).Patients with chronic low back pain of facetogenic origin comprise 15% to 45% of all low back pain patients based on the criteria of the International Association for the Study of Pain. The treatments utilized in managing chronic low back pain of facetogenic origin include intraarticular injections, medial branch nerve blocks, and radiofrequency ablation of medial branch nerves. A randomized controlled trial performed to evaluate the effectiveness of lumbar facet joint nerve blocks found that participants experienced significant improvement with significant pain relief (ClinicalTrials.gov Identifier: NCT00355914). The trial included 60 patients in Group I with local anesthetic, and 60 patients in Group II with local anesthetic and steroid. The inclusion criteria were based on a positive response to the diagnostic lumbar facet joint blocks using local anesthetic. Results were documented at baseline, 3 months, 6 months, and 12 months. Trial results were excellent in both groups of patients, requiring approximately 3 to 4 treatments in 12 months, with an average relief of 15 weeks per episode of treatment. This study concluded that therapeutic lumbar facet joint injections, with or without steroid, provide a good option for pain relief in patients with confirmed facetogenic low back pain. In this case, the patient has been diagnosed with facetogenic pain and his last sets of injections provided him with 50 percent relief. As such, the requested repeat facet injections at L4-5 and L5-S1 bilaterally are reasonable, appropriate, and medically necessary for management of the patients low back pain. Accordingly, the requested facet joint injection procedure (CPT 64493) is medically necessary for the patients medical condition.Final Result: The reviewer determined that the requested services are medically necessary for 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: Experimental/Investigational
Decision: Upheld

A 49-year-old male enrollee has requested Botox injections for the treatment of his occipital neuralgia. Findings:  Three physician reviewers found that the patient has a chronic pain syndrome with myofascial pain in the neck and head and a diagnosis of occipital neuralgia. Botox injections are not FDA approved for these indications. Other than a few case reports and small open-label case series, there is no evidence Botox can effectively relieve the symptoms of occipital neuralgia.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for image-guided sacroiliac joint injection. Researchers completed a systematic review of sacroiliac joint injections for low back pain. The authors concluded that, No single physical examination maneuver predicts response to diagnostic injections. When at least three physical examination findings are present, sensitivity, and specificity increases significantly. In relation to the evidence supporting the procedure, authors stated that, Two randomized controlled trials and multiple observational studies supported the effectiveness of therapeutic sacroiliac joint injections. Another study evaluated the diagnosis and treatment for sacroiliac joint pain and found that Diagnosis was made with three or more positive provocation tests, with the highest sensitivity being Faber (91.4%) and lowest probability was Gaenslen test. In this case, the patient presents with pain over the sacroiliac joint region bilaterally. Treatment has included radiofrequency ablation of the lumbar facet joint with good relief in the area. Recent physical examination included positive tenderness to palpation over the sacroiliac joints bilaterally as well as positive findings on three provocation tests of the sacroiliac joint. The patient has not demonstrated any focal neurological deficits and previous straight leg tests were negative. Medication use is limited due to sensitivity and physical therapy was attempted prior to the provider recommending sacroiliac joint injections. Based on the medical records for review and current medical literature, the requested image-guided sacroiliac joint injection is medically necessary for 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 anesthesiology with subspecialty certification in pain management 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.