Persius/imr-appeals huggingface dataset:
Appeal type: Urgent Care
Decision: Overturned

Nature of Statutory Criteria/Case Summary: According to the documentation submitted for review, the patient presented with right-sided abdominal pain. Although symptoms commenced gradually, the pain had worsened and become persistent. There is no single historical, clinical, or physical finding sufficient to rule out appendicitis. Localization to the right lower quadrant occurs as the natural course progresses and the time from onset of symptoms to diagnosis varies considerably. Based on the clinical documentation submitted for review, the patients right lower quadrant abdominal pain symptoms were severe and persistent and met an emergent medical condition. For the reasons provided, the medical services provided were emergency medical services. Final Result: The reviewer determined that the patient received emergency medical services on the date of service at issue. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in emergency 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested a Body Buoy specially designed custom body vest or functionally equivalent specially designed custom body vest for treatment of her medical condition.  Findings:  Three physician reviewers found that the medical evidence has not established the superior effectiveness of the requested equipment.  The Body Buoy serves as minimal posture corrector during sleep or during very active physical activities. There is a lack of evidence-based criteria to indicate that the Body Buoy improves pain or function in controlled studies.  Therefore, the requested equipment is not likely to be of greater benefit than other treatment options. Final Result: Three reviewers determined that the requested equipment is 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:   All three reviewers are board certified in neurology and are 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for cryoneurolysis for the right knee. Mihalko and colleagues note that per-protocol analysis suggests that preoperative cryoneurolysis in patients with knee osteoarthritis may reduce opioid consumption and improve functional outcomes after total knee arthroplasty (TKA). Dasa and colleagues report that a preliminary retrospective study showed that perioperative cryoneurolysis in combination with multimodal pain management may significantly improve outcomes in patients undergoing TKA. The authors noted that while these results were promising, further investigation of this novel treatment in prospective, randomized trials was warranted. These studies were not conducted at a large volume and were not sufficiently long-term to allow for conclusions and outcomes to be drawn regarding pain reduction and/or functional improvement in the long-term. In a sham-control prospective clinical trial with six-month follow-up, Walega and colleagues reported that cooled radiofrequency ablation of the superior lateral, superior medial and inferomedial genicular nerves, when performed two to four weeks prior to elective TKA as part of a multimodal postoperative pain management regime, had no measurable effect on postoperative opioid use, analgesia use or function in the 48 hours following surgery. The authors further noted that there was no longer term effect on outcome measures at one, three, and six months after TKA. In this case, the patient has a diagnosis of osteoarthritis and is scheduled for a TKA with cryoneurolysis for perioperative pain management. However, there is a lack of evidence in current medical literature supporting the efficacy, safety, and long-term effects of the requested service. Therefore, cryoneurolysis for the right knee is not likely to be more beneficial for treatment of the patients condition than any available standard therapy.Findings:  Three of the three physician reviewers found the requested cryoneurolysis for the right knee 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 service is 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollees parent has requested reimbursement and prospective authorization and coverage for food induction program (FIP) from October 2021 and going forward. Medical literatures note that the general approach to diagnosis and treatment of food allergy includes immunoglobulin (Ig) E measurements to specific foods in question for a patient. However, current medical literature does not support an extensive array of blood tests, such as food IgG testing, examining foods to which a patient has not had a reaction or oral desensitization trials for a multitude of foods to which there is no documented history of anaphylaxis. There is a lack of evidence supporting oral dosing protocols for foods that are considered intolerances or IgE mediated allergies based on IgG and patch testing. Therefore, FIP was not and is not likely to be more beneficial for treatment of the patient's condition than any available standard therapyFindings:  Two of the three physician reviewers found the FIP at issue was not and 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 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 reviewer 1 is board certified in internal medicine and 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 and 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: Experimental/Investigational
Decision: Upheld

A 54-year-old female enrollee has requested a CTA for evaluation of coronary artery disease.   Findings:  Two physician reviewers found that there is no evidence the patient has had other forms of acceptable evaluation for risk stratification such as nuclear spect imaging or stress echo imaging.  In addition, the need to start statin therapy should not be based on CTA, but rather, the patients lipid profile, as the earlier has never been a clinical indication for such therapy. In this setting, other acceptable forms of risk stratification exist. Currently, CTA has not been shown to be of significant clinical benefit for patients such as this patient.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested an office consultation with a plastic surgeon for evaluation of her hypertrophy of breast.  Findings:  The physician reviewer found that the submitted documentation supports the medical necessity for the requested consultation. The patients clinical condition warrants an evaluation by a plastic surgeon. Per the record, this patient has severe symptomatic macromastia and has failed conservative management of pain control and chiropractic treatment.  Winn and colleagues support the use of a relatively thorough evaluation with respect to macromastia. In addition, evidence-based clinical studies indicate that symptoms of macromastia can be improved by breast reduction.  The patient has well-documented chronic upper back pain and shoulder grooving directly associated with her severe macromastia. The patients condition of macromastia is causing functional problems and would likely benefit significantly from reduction surgery. In summary, the patient has a functional problem that is directly related to her significant macromastia.  Breast reduction is a well-known procedure that directly addresses this functional deficit.  Therefore, a consultation with a plastic surgeon is medically necessary in the evaluation and treatment of the patients medical condition. Final Result: The reviewer determined that the requested consultation is 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 plastic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 56-year-old male has requested an oxygen and nicotine patch 21mg. for treatment of his chronic obstructive pulmonary disease (COPD).  Findings:  The physician reviewer found that the information provided does not support the medical necessity for an oxygen and nicotine patch 21mg. Currently, the medical literature does not support domiciliary oxygen therapy in patients with reduced arterial partial pressure of oxygen greater than 55 mmHg at rest (Jindal and Agarwal). The records do not indicate the patient has a reduced arterial partial pressure of oxygen of less than 55 mmHg. As such, the requested oxygen has not been demonstrated to be medically necessary in this patients case. In addition, the requested nicotine patches are not supported as medically necessary in treating this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

A 40-year-old female enrollee has requested a wearable cardioverter defibrillator vest for the treatment of her peripartum cardiomyopathy. Findings:  Two physician reviewers found that the cardioverter defibrillator vest is a device approved by the Food and Drug Administration (FDA) with significant documentation and data supporting its use.  It is particularly effective in younger patients and in situations in which the use of a defibrillator is likely to be temporary.  The disadvantage of the device is principally seen in older patients since it does not have pacing capabilities and bradycardia may follow the delivery of a shock to correct ventricular fibrillation. Based upon the information submitted, it is the best treatment option for this patient.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential treatment services provided for treatment of his behavioral health conditions.Findings:  The physician reviewer found that with records to the patients recovery, the records support a score of 2 regarding environmental stress. The patient had a mildly stressful environment.  He reported that he did well socially and made friends easily. His friends are supportive. He has a good relationship with his parents. Stress from the home came mainly from expectations for performance at school and at home which were not being met. In terms of environment support, the records support a score of 2.  The patient had a supportive environment.  Both parents are supportive and would participate in care if requested to do so. Regarding significant response to treatment, the records support a score of 2. The records noted that the patient had improved significantly. Regarding acceptance and engagement, the patient scored 2. At the initiation of treatment, the patient was obstructive with treatment. Subsequently, the patient was able to develop positive relationships with his clinicians and care providers. Overall, the patient has a composite score of 15.  Based on these criteria, the patient could have been discharged to a less restrictive environment as an outpatient. All told, residential treatment services provided were not medically necessary for the treatment of this patient.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 reviewer is board certified in psychiatry with expertise 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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Lyrica for treatment of the enrollees severe nerve pain from small fiber neuropathy. Findings:  The physician reviewer found that The records indicate that this patient developed a neuropathic pain related to a small fiber neuropathy that failed to respond to several medications including gabapentin, tramadol, Celebrex, pramipexole, low dose naltrexone and amitriptyline. Several studies have demonstrated the efficacy of Lyrica in neuropathic pain. Although most of the current studies have focused on the efficacy of Lyrica in diabetic neuropathy, the data suggests that Lyrica would also be effective in non-diabetic neuropathy. Other studies demonstrated that Lyrica is effective in toxic neuropathy and neuropathy in the orthopedic setting. Given this support, the requested Lyrica is supported as medically necessary for treatment of this patients severe nerve pain from small fiber neuropathy. 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 sub-specialty certification in neuromuscular 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

The parent of a 21-month-old female enrollee requested inpatient hospitalization stay for medical treatment of the enrollees nasojejunal (NJ) tube dislodgement.  Findings:  The physician reviewer found that this patient presents with a complex medical history including recent liver transplantation and was admitted to the hospital after her NJ tube became dislodged. The submitted records indicate the patients hospital course was limited to repletion of IV fluids until her NJ tube was replaced and continuation of home medications. While the patient did not meet criteria for acute inpatient admission, her multiple comorbidities and clinical fragility necessitated an observational level of service. Thus, based on the medical literature cited above and the documentation submitted for review, an observational level of care was medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

A 37-year-old female enrollee has requested gonadal and pelvic venogram with embolization and sclerotherapy of gonadal and abnormal pelvic veins for treatment of her pelvic congestion syndrome.  Findings:  Three physician reviewers found that the presence of varices of the pelvic veins has been shown to be the underlying etiology in a significant proportion of patients with chronic pelvic pain. The development of these varices is caused by a combination of endocrine and mechanical factors. Given the positional nature of these varices, they are rarely diagnosed with conventional methods such as B-mode ultrasound and diagnostic laparoscopy. Diagnosis is best made with selective ovarian venography, although newer, non-invasive methods such as MRI and duplex ultrasound are becoming more common. Pelvic varices are treatable, either using ovarian suppression or by the ligation or embolization of the pelvic veins. Indications for ovarian vein coil embolization include dilatation of the ovarian vein greater than 5 mm, ovarian vein reflux into the pelvic cavity involving incompetent valves, severe congestion of the pelvic venous plexus, and significant stasis of contrast medium in the pelvic veins, abnormal filling of the pelvic veins across the midline, and filling of vulvovaginal or thigh varicosities. Overall, there is adequate scientific data to support the requested services as likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Trulicity. This patient presents with a history of type 2 diabetes. Patient has struggled with control of the condition with use of metformin, insulin, and sulfonylurea. The patients provider has recommended treatment with Trulicity, which is a member of the GLP-1 analogues, a class of drugs used in the treatment of type 2 diabetes that mimic the endogenous hormone GLP-1. As noted in the medical literature, GLP-1 analogues such as Trulicity have been demonstrated to provide significant improvements in glycemic control and weight loss as well as provide potential improvement in cardiovascular risk factors (Verges, et al.). Another important benefit of Trulicity relates to potential improvements in beta cell function, which is likely to halt or slow the progression of diabetes (Vilsboll and Garber). One recent study reported that Trulicity is associated with a substantial reduction in the risk of a major adverse cardiac events (Scott). Given this support, the requested Trulicity is medically necessary for 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 internal medicine with subspecialty certification in diabetes, endocrinology, 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.
Appeal type: Medical Necessity
Decision: Upheld

A 53-year-old male enrollee has requested authorization and coverage for fluoroguide for spine injections (lumbar/sacral) for treatment of his low back pain with sciatica.  Findings:  The physician reviewer found that in the medical literature, Vad and colleagues reported that fluoroscopically guided transforaminal epidural injections serve as an important tool in the nonsurgical management of lumbosacral radiculopathy secondary to a herniated nucleus pulposus. Botwin and colleagues found that fluoroscopically guided transforaminal epidural steroid injections may help reduce unilateral radicular pain and improve standing and walking tolerance in patients with lumbar degenerative spinal stenosis. Rosenberg and colleagues noted that epidural steroid injections can offer significant pain reduction for up to one year after initiation of treatment in patients with discogenic pain and possibly in patients with spinal stenosis. An epidural steroid injection is indicated for pain associated with lumbar radiculitis/radiculopathy. Radiculitis is consistent with abnormal reflexes, straight leg raise, paraspinous tenderness and possibly motor weakness. This patients physical exam does not reveal these findings and there is no imaging demonstrating a disc bulge or nerve root compression. In addition, his pain and physical exam findings are not consistent with lumbar radiculopathy. Thus, the requested fluoroguide for spine injections (lumbar/sacral) is not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The patients parent has requested authorization and coverage for occupational therapy and assessment with a therapist certified in sensory integration and/or speech therapy. There is a discrepancy between the results of the autism evaluations. However, the evaluation performed by the independent provider included assessment of the patients pragmatic and social language, which do not appear to have been fully assessed in the initial evaluation. Speech therapy to address difficulties with social and pragmatic language is medically necessary for the patient. Medical literature states that the substantial influence of pragmatic language abilities on social function and in resolving interpersonal conflicts with peers needs to be considered in children with autism. Although occupational therapy and a thorough assessment are medically necessary, an assessment with a therapist certified in sensory integration is not medically necessary for the patient, because there is insufficient evidence in the medical literature to support the use of sensory integration based therapy. Sensory integration therapy has been a popular treatment for children with neurodevelopmental disorders but there is significant controversy regarding its effectiveness. The American Academy of Pediatrics states that, parents should be informed that the amount of research regarding the effectiveness of sensory integration therapy is limited and inconclusive. Given the current medical literature and guidelines, an occupational therapy assessment and treatment is with a provider not certified in sensory integration therapy and speech therapy are medically necessary for this patient. Final Result: The reviewer determined that a portion of the requested services are 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 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.