Persius/imr-appeals huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Botox injections. Findings: Two of the three physician reviewers found that in this case, there is no clear documentation of symptoms typically associated with thoracic outlet syndrome versus other etiologies of arm symptoms. There is no clear documentation in the records of objective evidence on examination or other diagnostic testing of vascular or neurogenic thoracic outlet syndrome, the latter of which is due to brachial plexus compression, predominantly affecting the lower trunk of the brachial plexus. Anterior scalene muscle blocks have been used in the evaluation of suspected neurogenic thoracic outlet syndrome, but these have poor specificity for neurogenic thoracic outlet syndrome and poor confirmatory reliability. There is limited published literature related to the use of botulinum toxin for the treatment of thoracic outlet syndrome. There have been small studies and case series suggesting the possibility of some clinical efficacy of this treatment. However, there is a lack of published high grade studies, such as well-conducted randomized controlled or cohort trials, to establish the efficacy of this intervention.  In this case, the requested services are not likely to be more effective than ongoing empiric therapy, exercises and palliative interventions, such as analgesics and topical modalities. Therefore, the requested Botox injections are not likely to be of greater benefit than other treatment options. 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 reviewers 1, 2 and 3 are board certified in enrollee has requested authorization and coverage for Botox injections 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: Urgent Care
Decision: Upheld

A 55-year-old female enrollee has requested emergency services for treatment of her wrist.  Findings:  The physician reviewer found that the submitted clinical documentation fails to demonstrate that a prudent layperson would have sought immediate medical attention on the date in question. In this case, the wound recheck and dressing change performed on the date indicated was not emergent in nature. The services provided on the date indicated consisted of a routine follow-up assessment of a laceration repair and could have been performed by the patients primary care physician. A prudent layperson would not have thought this to be an emergency medical condition requiring immediate medical attention in an emergency department. Although it appears the patient was instructed to return to the emergency department for a follow-up evaluation at the time she originally presented for treatment, there is no evidence that the patients symptoms on the date of service in question would have caused a prudent person to believe the follow-up care was emergent in nature. Thus, the patients symptoms on the date indicated did not meet prudent layperson criteria for emergency care.
Appeal type: Experimental/Investigational
Decision: Upheld

A 51-year-old male enrollee requested authorization and coverage of metal-on-metal hip resurfacing. The Health Plan denied the request indicating that the requested procedure is considered experimental for treatment of the enrollees left hip osteoarthritis.Three physician reviewers performed a medical necessity Independent Medical Review. Two physician reviewers concluded that the requested procedure is not likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy. One physician reviewer concluded that the requested procedure is likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy. Because two of the three physician reviewers concluded that the requested treatment is not likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy, the Health Plans denial has been upheld.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for occupational therapy services. Occupational therapy focuses on deficits in visuospatial, neurodevelopmental, and fine motor skills. This treatment modality addresses weakness of upper extremities including hands, as well as coordination deficits. The purpose and goal of occupational therapy in this patients case is to develop and improve skills needed to perform age appropriate activities for daily living and school performance. This patient presents with dysgraphia. He exhibits deficient ability to initiate, plan, organize and monitor letters and words on paper. These executive and motor difficulties accompany young patients with dysgraphia in various domains such as home, community, and school environments. This patient requires occupational therapy to learn and develop skills such as tying his shoelaces, writing, and reading at an age-appropriate level. Therefore, the requested occupational therapy services are 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 physical medicine and rehabilitation with subspecialty 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: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested Harvoni for eight weeks for treatment of his hepatitis C virus.  Findings: The physician reviewer found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America, all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. This applies regardless of fibrosis stage or viral load. However, different treatment regimens are recommended depending on presence of cirrhosis and treatment history.  Patients with cirrhosis and patients who have failed therapies such as peg-interferon, Sovaldi, or Harvoni may require different treatment regimens.  Per the guidelines, only non-cirrhotic treatment-naive genotype 1 patients with viral load can be treated with Harvoni for eight weeks.  Other patients may require longer or different therapy.  Viral load, treatment history, and some assessment of cirrhosis are required to determine the medical necessity of treatment.  For these reasons, the requested treatment with Harvoni for eight weeks is not supported as medically necessary based on the provided information.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 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

A 47-year-old female enrollee has requested residential inpatient services for the treatment of her behavioral health problems. Findings:  The physician reviewer found that based on the records for the period in dispute, no further active inpatient care was warranted. There is no evidence in the submitted records of an acute need or risk requiring 24-hour inpatient care beyond the last authorized date of service. This patient could have been readily discharged with continued outpatient follow-up with a psychiatrist
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for minimally invasive lumbar laminectomy and interbody fusion L4-S1. In this case, the patient presents with severe, intractable lower back and leg pain and has failed standard non-operative treatments. She reports chronic pain. Diagnostic imaging shows severe degenerative disc disease at L5-S1, with more moderate degenerative changes at L4-5. In this clinical setting, given that the patient has failed several years of nonsurgical care and that the provider has identified the L4-S1 segments as likely pain generators, the requested service is medically necessary. Therefore, minimally invasive lumbar laminectomy and interbody fusion L4-S1 is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested service 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 neurological 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a low dose CT scan of the lungs. The submitted documentation supports that the requested services are medically necessary. The patient is considered high risk based on his personal smoking history as well as his family history of lung cancer. Two findings that necessitate follow-up on the most recent CT include a new partially solid nodule as well as increased size of a solid nodule. According to the American College of Radiology lung CT screening reporting and data system, or LUNG-RADS, the new partially solid nodule qualifies as a category 3 nodule, requiring six month follow-up CT. Additionally, the increase in size of the solid nodule also warrants follow up. Under these circumstances, six month follow-up chest CT scanning is medically necessary to demonstrate stability of both of the nodules. Accordingly, a low dose CT scan of the lungs is medically necessary to treat the patients medical condition.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 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: 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 this patient has a history of speech and language delay and should receive appropriate intervention including speech therapy. Given the support in the medical literature for the efficacy of speech therapy in patients with speech delay, this patient should have ongoing monitoring of appropriate social, emotional, and language development. All told, the requested speech therapy has been established as medically necessary in this patients care and should be approved for the recommended frequency. The patient should be re-evaluated at the end of the approved period to determine whether progress has been made and whether further services are clinically indicated.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a left lower extremity computed tomography (CT) scan. The American College of Radiology (ACR) has established appropriateness criteria to help physicians obtain imaging in the most efficacious and appropriate manner. In their recommendations for non-traumatic knee pain, the ACR describes multiple variants. The ACR considers x-rays to be the most appropriate study and CT scanning the least appropriate examination to perform. On occasion, if an MRI cannot be performed, the ACR will consider a CT arthrogram to be appropriate, but that is not being considered for this patient. Similarly, the ACR has established criteria for the evaluation of chronic hip pain, and again CT scanning is considered not appropriate. For chronic venous disease in the lower extremity, the ACR does not mention CT scanning as a possibility. In this case, the rationale for obtaining a CT scan of the patients left lower extremity is unclear. There are many possibilities which could explain the patients left leg and hip pain. For very few of them is a CT scan indicated. Diagnosing osteoarthritis, for example, is generally made by obtaining x-rays, and then correlating with physical examination. In some circumstances, an MRI is appropriate for diagnosing specific ligamentous abnormalities, such as a torn meniscus, but CT scanning is not an appropriate means to evaluate ligaments or cartilage. Similarly, a systemic arthropathy such as rheumatoid arthritis is not diagnosable by CT scanning. The patients chronic DVT could conceivably cause chronic leg pain due to venous congestion or inflammation, but this also is not diagnosable by CT scanning. In conclusion, CT scanning would not be an effective way to diagnose this patients chronic left leg and hip pain.Final Result: The reviewer determined that the requested service 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 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: Overturned

The father of a 17-year-old female enrollee has requested Botox injections for treatment of the enrollees migraine headaches. Findings:  Two physician reviewers found that the patient has refractory chronic daily headache. She has failed or been intolerant of more than three preventive agents. It is also likely that the patient has medication overuse headaches related to her daily use of Dilaudid. It is important that she taper off the Dilaudid as it will only lead to worsening headaches over time. Botox is very likely to be effective in treating the patients headache disorder.
Appeal type: Medical Necessity
Decision: Upheld

A 36-year-old male enrollee requested authorization and coverage of thoracic sympathectomy. The Health Plan denied the request indicating that the requested procedure is not medically necessary for treatment of the enrollees hyperhidrosis.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested procedure is not medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the computer assisted musculoskeletal surgical navigational (CPT code 0054T bone srgry cmptr fluor image) for treatment of the enrollees right hip degenerative joint disease secondary to osteoarthritis.Findings:  Two physician reviewers found that one study published a 10-year randomized controlled study of computer-assisted surgery for cup placement in total hip arthroplasty. Overall, 60 patients were randomized into two groups using either the computer assisted surgery technique or a conventional technique for cup placement. The authors concluded that computer assisted surgery for cup placement does not confer any substantial advantage in function, wear, or rate of survivorship at 10 years after total hip arthroplasty. Another study reported that there have been substantial advancements in computer assisted total hip arthroplasty but it is still controversial due to the steep learning curve, intraoperative technical issues, and increased operative time. Final Result: Two reviewers determined that the service at issue was 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 physician reviewers 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: The patient has requested authorization and coverage for Otezla 30 mg. A study notes the severity of psoriasis is generally defined by the total BSA involved, with BSAs of 3% to 10% considered moderate disease. Another study notes therapeutic options for moderate to severe plaque psoriasis include oral phosphodiesterase 4 inhibitors, such as Otezla. In this case, the documentation reflects the patients psoriasis affected 10% of BSA, putting the disease in the moderate category. As such, the requested medication is medically indicated. Therefore, Otezla 30 mg is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in dermatology 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

Nature of Statutory Criteria/Case Summary:  An enrollee has requested breast tomosynthesis for evaluation of her medical condition. Three physician reviewers found that the current medical evidence supports the services at issue in this clinical setting.  The addition of breast tomosynthesis to the screening examination has gained worldwide acceptance due to the associated decrease in callbacks and increase in the detection of small cancers.  Per the medical literature, the addition of breast tomosynthesis to digital mammography was likely to have been of greater benefit to the patient than digital mammography alone.  All told, breast tomosynthesis was likely to have been superior over other methods of evaluating this patient.  Final Result:  Three 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: Upheld

The patient is a 39-year-old female who is a highly active person status post surgical knee repair. She reports she continues to exhibit weakness in the affected knee. A custom knee brace has been prescribed by the patients physician. The Health Plan has denied coverage for the requested brace on the basis that it is not medically necessary for treatment of the patients medical condition.The Health Plans denial should be upheld. There is no Class I literature/evidence to support the need for the requested knee brace for this patient. Furthermore, the patient underwent surgery over a year ago and her knee is now stable. The patient wishes to have the brace so that she may participate in sporting activities. There is no evidence establishing that a custom brace is necessary for the patient to return to athletic activities.  Therefore, I have determined that the requested equipment is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Overturned

The parent of a three-year-old female enrollee has requested Synagis injections for treatment of the enrollees chronic lung disease, oxygen dependence, and prematurity.  Findings:  Three physician reviewers found that there is adequate data in the peer-reviewed medical literature to support the use of Synagis prophylaxis in this patient with a recent history of RSV treated with high flow oxygen. This patients elevated risk for disease has been demonstrated by her already acquiring the RSV this winter requiring treatment in intensive care. Although the likelihood of a severe RSV infection typically decreases when a patient reaches two years of age, this patient is maintained at home with supplemental oxygen and diuretic therapy. Thus, she remains at risk for contracting RSV again this season and she lives with two young children who attend either daycare or school. All told, the requested Synagis vaccine is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.