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

The parents of a 17-year-old female enrollee  requested authorization and coverage of locked residential treatment for the treatment of mental disorders.  The Health Plan denied the enrollees request indicating that the requested treatment is not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer upheld the health plans denial on the basis that the requested services are not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 54-year-old female enrollee requested authorization and coverage of an MRI of her right breast. The Health Plan denied the request indicating that the requested MRI is not medically necessary for evaluation of the enrollees right breast.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plans denial on the basis that the requested MRI is medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

A 25-year-old male enrollee has requested Ketamine combined with another medication that serves as a booster for the Ketamine for medical treatment of his leg pain.  Findings:  The physician reviewer found that Ketamine combined with another medication that serves as a booster for the Ketamine is not medically necessary for this patients chronic medical condition. This patient failed to receive benefit with previous Ketamine infusions. Moreover, the patients chronic pain condition is not consistent with complex regional pain syndrome. Given the lack of an appropriate indication for Ketamine, the requested combination therapy including Ketamine and a medication to serve as a booster for the Ketamine is not medically necessary for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Physician 1: The patient is a 41-year-old woman with chronic back pain. A request has been made for an intradiscal electrothermal therapy (IDET) procedure. The Health Plan has denied this request on the basis that IDET remains experimental/investigational.There is no information available to warrant and support the use of IDET in the treatment of this patient. No long-term prospective study has shown significant long-term benefits, and the risks of the therapy are still unclear. In this community, when IDET has been used the results have been poor. As such, IDET cannot be recommended until the efficacy of the procedure has been established. Therefore, I have determined that 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.Physician 2: The patient is a 41-year-old female who had an injury to her back approximately four years ago. The submitted information indicates the patient had a positive discogram at L4-L5. Her pain is being managed on high-dose narcotics. The patients provider indicates the patient is not a surgical candidate. It has been recommended the patient undergo an intradiscal electrothermal therapy (IDET) procedure. The Health Plan has denied authorization for IDET on the basis that the efficacy of the procedure remains unproven.IDET at L4-L5 is not likely to be successful in this patient who had a positive discogram at levels L4-L5 and L5-S1. IDET remains an unproven procedure without clearly defined efficacy. IDET is not the standard of care and it is not in the mainstream of lumbar degenerative disc disease treatment, particularly when there is more than one disc involved. Review of the medical literature reveals several studies showed little to no efficacy associated with the IDET procedure. Therefore, I have determined that 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.Physician 3: The patient is a 41-year-old female with chronic low back pain. She has failed conservative management and therefore, wishes to undergo an intradiscal electrothermal therapy procedure (IDET). The Health Plan indicates there is insufficient peer-reviewed evidence demonstrating the effectiveness of IDET for treatment of low back pain.Despite its widespread use, the efficacy of the IDET procedure remains elusive. Numerous peer-reviewed studies have failed to demonstrate its efficacy. At this time, IDET remains an unproven procedure. There is no substantial proof of its effectiveness for the treatment of chronic back pain. Therefore, I have determined that 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: Upheld

This patient is a 52-year-old man who has hepatitis C genotype 1A. He was once treated in 1997 with regular IFN and apparently did not respond. It appears that he had a six-month course of therapy at that time. More recently, the patient was treated with Pegasys and ribavirin for 48 weeks and his last primary clearance rate was apparently undetectable. Another six months of therapy has been requested by his provider. The Health Plan has denied this request on the basis it is not medically necessary for treatment of the patients condition.Review of the submitted records reveals that continuation of Pegasys and ribavirin therapy is not medically indicated for treatment of this patients hepatitis C virus. It is not the community standard to treat genotype 1 patients for 18 months with increased dosage of ribavirin. The requested therapy is not likely to be of benefit. The submitted evidence indicates the patient failed one course of therapy. Furthermore, with the more recent course of therapy the patient did not have a 2-log drop in his viral count after 12 weeks of therapy. Based upon a study by Fried, et al., only 3% of patients who did not experience a 2-log drop by the end of 12 weeks had sustained viral response by the end of the treatment course. In light of these findings, there is no medical justification for continuation of Pegasys and ribavirin therapy for treatment of the patients hepatitis C virus. Therefore, I have determined that the requested therapy is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

A 39-year-old female has requested ten or more additional sessions of intensive outpatient treatment for treatment of her bulimia nervosa. Findings:  The physician reviewer found that the literature supports the fact that patients generally remained at their discharge level of recovery over time, as noted by Zeeck and colleagues.  Her prior treatments appeared to have inadequately controlled her eating disorder symptoms. In this patients case, ten additional sessions of intensive outpatient treatment are medically indicated.  She meets the American Psychiatric Association criteria for intensive outpatient treatment. The patient will likely deteriorate at a lower level of care, and she needs further intensive services due to her comorbid conditions.  A reassessment after ten intensive outpatient program sessions is needed in order to determine the medical necessity of future services.
Appeal type: Medical Necessity
Decision: Upheld

A 47-year-old female enrollee has requested Synvisc One injection for treatment of her knee osteoarthritis. Findings:  The physician reviewer found that carefully conducted double-blinded studies published in the medical literature do not demonstrate any clinical effect from hyaluronan injections. In addition, there is a recognized incidence of aseptic inflammatory reactions due to allergic response and risk of iatrogenic infection within the joint. A recent meta-analysis on the review of a total of 89 trials involving 12,667 patients with knee osteoarthritis reported that viscosupplementation is associated with a small and clinically irrelevant benefit and that there is an increased risk of serious adverse effects (Navarro-Sarabia, et al). Several studies evaluating repeated treatment protocols have also reported adverse events including inflammatory changes within the knee joint. Further, the risk of sensitization is expected to increase after repeated exposure to an antigenic substance. Given the lack of benefit demonstrated in well-designed, double-blinded studies and the documented incidence of acute local reactions, the requested Synvisc injections are not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 38-year-old male with a history of disc herniation at L4-5. The patient received three physical therapy treatments in September 2004. On 11/3/04, a neurosurgeon recommended further physical therapy. The Health Plan indicates further physical therapy was not medically necessary as of 12/17/04 because the patient had a level of function within normal limits and did not have pain.Review of the submitted notes indicates the patient was not pain free on 12/17/04. While a treatment note of 12/17/04 indicates the patient was independent in core stabilization on flexibility program, treatment notes through 1/25/05 show the patient was continuing to make gains. His strength improved to 4+/5. He was educated in body mechanics and posture and had increased tolerance for sitting, standing, and walking with no signs of neurologic involvement. The therapy at issue was of reasonable duration with good progress documented. Therefore, I have determined that the therapy at issue was medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested chiropractic care for treatment of her neck pain and migraines. Findings:  The physician reviewer found that the documentation provided does not support the medical necessity for the requested services in this clinical setting. The medical literature demonstrates that cervical manipulation and mobilization produced similar changes in individuals.  While there is some low quality data to support cervical manipulation for pain reduction, and increased function in acute pain, further research is recommended. The physician already put in a referral to a physical therapist. In this patients case, physiotherapy was recommended by her provider. There were no results from her sessions with the physical therapist who is able to do mobilizations. The patients submitted records do not demonstrate that this treatment option has been tried and failed. Although some results are promising for chiropractic care, the medical necessity criteria  has not been convincingly shown in this patients case. According to the records, physiotherapy has not been initiated. Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in chiropractic care and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 25-year-old male with back symptoms that have not responded to medication or physical therapy. The patient has attempted closed and open MRI scans without success because of severe claustrophobia. For two of the attempts the patient took oral anti-anxiety medication. The Health Plan approved the open and closed MRI scans. The patients provider has requested a stand-up MRI, which the Health Plan has denied. The alternative service offered by the Health Plan is a closed MRI with conscious sedation. The patient states he has a past history of problems with intravenous sedation.There is no dispute that an MRI of the patients spine is medically necessary. There is some risk involved with conscious sedation. Furthermore, because of the patients high level of claustrophobia and his apparent prior history of problems with IV sedation there is likelihood the risks of conscious sedation are even greater in this patient. For these reasons, a stand-up MRI is medically indicated and appropriate for this patient. Therefore, I have determined the Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for acupuncture services. The submitted documentation supports the medical necessity of the requested services. This patient has a history of insomnia. She has tried melatonin, with limited benefit. The provider has indicated that even if the patients insomnia is related to her menses, hormones are not an appropriate treatment option given her history of breast cancer. In an undated letter, the patient clarified that her insomnia was worsened by her intermittent chronic pain. For chronic pain patients with limited therapeutic options, an acupuncture trial may be medically appropriate. There is sufficient support for the requested services in this clinical setting. All told, the requested acupuncture services 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 oriental 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 of Epclusa 400mg-100mg, once daily for 12 weeks and ribavirin 200 mg three times daily for three weeks. Findings:  The physician reviewer found that, according to joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. All patients should be treated, regardless of fibrosis stage.  Per the guidelines, cirrhotic patients are high priority for treatment, and Epclusa for 12 weeks is recommended as first-line therapy for treatment naive, genotype 3 patients. This is based on the ASTRAL-3 trial for Epclusa, which showed a high cure rate in compensated cirrhotic patients with this regimen.  However, the addition of ribavirin is not recommended by the evidence-based AASLD/IDSA guidelines noting that ribavirin is associated with significant adverse effects based on a study of ribavirin monotherapy. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, treatment with Epclusa monotherapy 400mg-100mg, once daily for 12 weeks is supported as medically necessary for the treatment of this patients hepatitis C infection, but ribavirin is not. Final Result: The reviewer determined that a portion of the requested medication regimen 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 internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for pharmacogenetic testing. Findings:  The physician reviewer found that International Society of Psychiatric Genetics states, Pharmacogenetic testing should be viewed as a decision-support tool to assist in thoughtful implementation of good clinical care. We recommend HLA-A and HLA-B testing prior to use of carbamazepine and oxcarbazepine, in alignment with regulatory agencies and expert groups. Evidence to support widespread use of other pharmacogenetic tests at this time is still inconclusive. Bousman and colleagues report that pharmacogenetic testing is unstandardized and conclude at present there are insufficient data to support the widespread use of combinatorial pharmacogenetics testing in clinical practice. In a table of pharmacogenetic associations, the U.S. Food and Drug Administration (FDA) explains, Specific information regarding therapeutic management is provided for some pharmacogenetic associations listed in the table, but most of the associations listed have not been evaluated in terms of the impact of genetic testing on clinical outcomes, such as improved therapeutic effectiveness or increased risk of specific adverse events. In addition, clinical studies, if available, may only have linked genetic variation to a drug's pharmacokinetics (such as the way in which the drug is metabolized), and differences in drug efficacy or safety across different genotype subgroups may not be known. If no statements related to efficacy or toxicity are provided, the scientific evidence the FDA reviewed was considered insufficient to support such associations. Given the lack of support in current medical literature for the routine use of pharmacogenetic testing for medication decision-making in psychiatry, the requested services are not medically indicated. In this patients case, pharmacogenetic testing is not in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, the requested service is not clinically appropriate in terms of type, frequency, extent, site, and duration. Therefore, pharmacogenetic testing is not medically necessary for the evaluation of this patient.Final Result: The reviewer determined that the requested service is not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in neurology with special qualification in child neurology with sub-specialty certification in neurodevelopmental disabilities 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 has requested authorization and coverage for Osmoprep 1.5 gram tablets. This patient presents with rectal bleeding, which is an indication for colonoscopy. The patient has not undergone a screening colonoscopy and rectal bleeding is concerning for colorectal cancer. As bowel preparation has been reported to be the primary obstacle to the patient undergoing a colonoscopy in the past, addressing the tolerability of bowel preparation is important. Comparisons of Osmoprep with conventional bowel preparation have generally shown that Osmoprep, which requires less intake and is thus better tolerated. As this patient has failed three conventional bowel preparations due to the required volume of liquid intake in the past, the requested Osmoprep is appropriate. For these reasons, the requested Osmoprep 1.5 gram tablets are medically necessary for 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 internal medicine with subspecialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 63-year-old male enrollee has requested for an intraocular lens implant to correct his left eye cataract condition. Findings:  The physician reviewer found that multifocal lenses are dependent on excellent macular function in order to provide any hope of improvement instead of degradation of vision. This patient did not have excellent macular function prior to surgery, and therefore was not an appropriate candidate for implantation of a multifocal lens.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a two-year-old male enrollee has requested speech therapy for treatment of the enrollees speech delay. Findings:  The physician reviewer found that the speech of this patient who is more than two-years-old is below a one-year level. His speech is significantly delayed, both by parental description and formal testing.  The etiology is due to a severe developmental delay in the maturation of speech.  There is no history of any prior developmental evaluations when the patients speech was evaluated.  Regarding medical necessity, it is the medical communitys standard practice to offer speech therapy to a two-year-old whose speech is at a one-year level.  There is a robust medical literature supporting speech therapy in this speech delayed population. Law, et al. reported that children with speech delay can be readily treated.  Speech-delayed children, such as this patient, with normal cognitive skills, are candidates for successful speech therapy (Goorhuis-Brouwer & Kniff).  Two-year olds who tested below the 10th percentile, as did this patient, do require and benefit from speech therapy (Emmanuel, et al. and Buschman, et al.).   In sum, speech therapy is medically indicated in this patient, with reassessment at six months. If the patient demonstrates improvement, but still has significant expressive speech delay, speech therapy should be continued.