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

A 39-year-old female enrollee has requested an interferential stimulator device for the treatment of her incontinence and sacroiliac joint dysfunction. Findings:  Three physician reviewers found that interferential stimulation therapy utilizing effects of low frequency electrical stimulation was first conducted on the lower urinary tract in the treatment of urinary incontinence in 1975. Interferential stimulation therapy for overactive bladder has been described in the medical literature in sporadic reports. The proposed utility of this therapy for conditions such as urinary frequency, urge incontinence, and stress incontinence was subsequently reported in these studies. However, there are no controlled or randomized controlled trials to confirm the efficacy of this treatment for these indications. At this time, the evidence supporting the benefits of interferential stimulation is lacking in both quantity and quality.
Appeal type: Medical Necessity
Decision: Overturned

A 49-year-old male enrollee has requested Actiq (fetanyl citrate) 400 mcg lozenges for treatment of his migraine headaches and cervical dystonia. Findings:  The physician reviewer found that while the FDA approval of Actiq is limited to tolerant cancer pain, its use for breakthrough, non-cancer pain has been discussed in several peer-reviewed articles. An article by Landy suggests Actiq is efficacious in the treatment of outpatient migraine headache and Taylor and colleagues discussed the impact of breakthrough pain on the quality of life in patients with chronic, non-cancer pain. From a clinical standpoint, it is medically reasonable to prescribe a dose of Actiq for this patient that will allow him to avoid or reduce the need for emergency room visits for episodes of acute, severe pain. In addition, the use of this breakthrough medication for this patient is limited to one to two doses every four weeks, and there is no clinical evidence that it is being abused or used as the main modality of treatment.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: Anenrollee has requested authorization and coverage for acyclovir 400 mg, oral tablet, once per day. This patient was diagnosed with herpes simplex infection. Oral acyclovir is effective treatment for herpes simplex infection. Specifically, oral acyclovir has been shown to decrease the duration of illness and symptoms severity (a study). In addition, prophylaxis is effective and indicated in this clinical setting. All told, the requested acyclovir 400 mg, oral tablet, once per day is supported as medically necessary for treatment of this patients medical condition. 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 sub-specialty certification in infectious disease 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

A 26-year-old female enrollee has requested pre-conception consultation with an endocrinologist for the treatment of her hypothyroidism. Findings:  The physician reviewer found that this patient has been diagnosed with hypothyroidism and recurrent miscarriage. Hypothyroidism is a recognized cause of recurrent miscarriage and monitoring of thyroid function including TSH and free T4 levels is required. This is standard of care and should be managed by a medical endocrinologist. It appears that the Health Plans policy would also support the requested pre-conception endocrinology consultation. It is clearly the most appropriate level of service considering the potential benefits and harms to the patient.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for breast tomosynthesis for evaluation of the enrollees risk for breast cancer.   Findings:  The physician reviewer found that the addition of three dimensional digital breast tomosynthesis to two dimensional full field digital mammography resulted in a significantly higher cancer detection rate and enabled the detection of more invasive cancers. Thus, although additional studies are needed to confirm these findings, there is adequate data to support the utility of three dimensional digital breast tomosynthesis in this clinical setting. Final Result: Two of the three reviewers determined that the diagnostic procedure at issue was 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: Physician reviewers number one, two, and three are board certified in diagnostic radiology 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 patients parent has requested authorization and coverage for physical therapy. The goal of treatment in pediatric cavovarus deformities is to establish a well-balanced foot with optimal plantar pressure distribution, to prevent progression or recurrence of the deformity, and prevent or postpone development of ankle, midfoot, and hind foot arthritis. In this case, the patient has failed non-operative treatment and has worsening deformity and pain with extended duration of physical activities. Based on the patients presentation and treatment history, physical therapy is not likely to change the outcome or the functional limitation resulting from this deformity. There is a lack of medical studies demonstrating that physical therapy will provide greater benefits over surgical intervention or orthotics to prevent recurring or progressive deformity or arthritis for this patient. All told, the requested physical therapy is not medically necessary for treatment of this patient. 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 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

The parent of a six-year-old male enrollee has requested the less invasive selective dorsal rhizotomy for treatment of the enrollees spastic diplegia cerebral palsy.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services in this patients case.  This patient has spastic diplegia cerebral palsy, and prior treatment has included physical therapy, bracing, and Botox injections into the lower extremities.  Despite prior care, the patient continues to remain symptomatic.  Although there is some support in the medical literature for the less invasive selective dorsal rhizotomy, there is a lack of class I or II evidence demonstrating that the requested services are superior to the open procedure.  While postoperative deformity is of concern after selective dorsal rhizotomy, there is a lack of supporting literature indicating that the incidence is significantly decreased by the requested procedure.  All told, the requested less invasive selective dorsal rhizotomy is not medically necessary for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

A 39-year-old male enrollee has requested for artificial disc replacement at C5-6 and C6-7 for treatment of his degenerative disc disease. Findings:  Three physician reviewers found that Artificial disc replacement is a new technique for management of cervical disc disease and is FDA approved. However, the long-term efficacy of this procedure is still unknown. The medical data regarding artificial disc replacement is not sufficient to promote it over standard spinal fusion.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 53-year-old male with diabetes mellitus type 2 that is poorly controlled (A1C of 8%) with 70/30 insulin. Based on the records provided, the patient has apparently not been seen by an endocrinologist. His primary care physician has recommended insulin pump therapy. The Health Plan has denied this request indicating that the requested equipment is not medically necessary for treatment of the patients medical condition.The Health Plans denial should be upheld. There is no evidence other alternative oral and/or insulin therapies have been tried by the patient. There are multiple alternative therapies to the patients current program including Novalog/Humalog insulin, bedtime NPH insulin, and the combination of oral agents and insulin. Additionally, there is no indication whether the patient has been compliant with his insulin injections, home glucose monitoring or diet. Furthermore, it does not appear the patient has undergone a specialty consultation with an endocrinologist. For these reasons, 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: Medical Necessity
Decision: Overturned

Findings:  The physician reviewer found that The patient has requested reimbursement for abdominal wall reconstruction surgery. Emanuelsson and colleagues state, Functional disability related to midline bulging of the abdominal wall is a common complaint in women after childbirth. Abdominal rectus diastasis (ARD) is a sequela of the expansion of the abdominal contents during pregnancy. Massive weight loss and/or congenital disproportion of the collagen III/I ratio may also result in ARD. The authors found no consensus on whether ARD should be considered a pathologic condition requiring operative attention. Strigard and colleagues state, The clinical significance of abdominal rectus diastasis (ARD) is debatable. Even though there are several studies indicating that weak abdominal integrity because of ARD causes symptoms of pain and weakness of the abdominal wall and a decreased quality of life, there are still authors who claim that ARD is just an aesthetic issue. Conclusive studies on the relationship between subjective symptoms and the width of ARD are lacking. Given the lack of conclusive studies on the relationship between subjective symptoms and the width of ARD, the abdominal wall reconstruction surgery performed on 9/8/21 was not medically necessary for treatment of this patient. The California reconstructive surgery statute requires health insurers to cover reconstructive surgeries, defined as surgery performed to correct or repair abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease to do either of the following: (1) to improve function; (2) to create a normal appearance, to the extent possible. In this case, the large diastasis rectus constitutes an abnormal structure of the body caused by trauma from both pregnancy and recent abdominal wall injury. The patient reports significant disability as a result of the rectus diastasis, and the purpose of the surgical repair was to improve function by reestablishing the normal position and function of the rectus abdominus muscles. Thus, the abdominal wall reconstruction surgery performed on 9/8/21 was reconstructive in nature for this patient. Final Result: The reviewer determined that the service was not medically necessary for treatment of the patients medical condition, but was reconstructive in nature. Therefore, the Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

A 60-year-old male enrollee requested the medication Harvoni for medical treatment of his hepatitis C.  Findings:  Two physician reviewers found that per American Association for the Study of Liver Diseases and Infectious Diseases Society of America recommendations, patients with chronic active hepatitis C should be treated with antiviral therapy regardless of fibrosis score.  Successful hepatitis C treatment results in sustained virologic response.  Therefore, regardless of fibrosis score, there is sufficient support for Harvoni in this clinical setting.  Harvoni has been approved for the treatment of hepatitis C, genotype 1 in both treatment-naive and treatment-experienced patients.  All told, Harvoni is medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 15-year-old female enrollee has requested residential treatment services for the enrollees alcohol abuse and major depressive disorder.  Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the services at issue.  Modern psychiatric practice aims to place patients in the least restrictive treatment setting.  In general, community settings optimize treatment gains.  However, transient placement in more restrictive settings is often clinically appropriate.  In this particular case, the residential services were for active treatment based on evidence-based principles.  The duration of the residential services was within typical community practice standards.  Additionally, the services facilitated diagnostic clarification and were reasonably expected to improve her condition and prevent a more serious illness.  Considering the case in its entirety, and applying the current practice guidelines and relevant peer-reviewed literature, residential treatment services provided from the specified timeframe were medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Klonopin for treatment of his behavioral health conditions. Findings:  The physician reviewer found that there is a lack of support for the requested medication in this patients case.  Benzodiazepines possess an array of potential side effects.  Disinhibition, cognitive dulling, perceptual disturbances and exacerbation of depression are common.  Additionally, there is growing concern of misuse, tolerance and dependence issues with this medication class.  As such, contemporary practice standards aim to minimize benzodiazepine therapy and optimize treatment alternatives.  This patient has been evaluated by two psychiatrists.  The first provider tapered the clonazepam, the second provider did not prescribe the medication.  The patient elected to not continue with intensive outpatient therapy to address his anxiety.  The frequency, duration and specific modalities of his current psychotherapy is unclear.  This is particularly significant as the best outcomes emerge from an evidence-based psychotherapy, which represents a first-line intervention for both depressive and anxiety disorders.  Additionally, the patient has not exhausted reasonable pharmacologic strategies to address his illness burden.  Doxepin is a sedating tricyclic medication used for insomnia, mood and anxiety.  Bupropion is a trusted noradrenergic-enhancing antidepressant. Having been initiated on both at conservative doses recently, the impact of the medication trials on the symptom complex is not yet declarative.  In sum, based on the documentation provided, it appears that the patient has not exhausted well-supported medication and non-pharmacologic treatment alternatives to address his depression and anxiety.  Therefore, the requested Klonopin is not medically indicated for the 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 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: Upheld

A 41-year-old male enrollee has requested for acute inpatient services for treatment of his shortness of breath.  Findings:  The physician reviewer found that the patient was admitted on an episode of shortness of breath. He did not present with symptoms of an acute coronary syndrome. His initial workup did not reveal an abnormal EKG or chest x-ray. However, his Troponin level was minimally elevated and was an indication for further workup. The patients Troponin level did not show further elevation. Since significant cardiac ischemia had been excluded, the patient could have been safely discharged.
Appeal type: Experimental/Investigational
Decision: Overturned

A 33-year-old male enrollee has requested  for radiofrequency thermocoagulation facet rhizotomy for treatment of his back pain. Findings:  Two physician reviewers found that radiofrequency thermocoagulation of the median branches for the treatment of chronic low back pain secondary to facet joint pain is an accepted technique. There is documented evidence that the procedure is safe and effective when performed for patients with retractable pain. There is sufficient evidence of the procedures efficacy to warrant its repeat use in this case. It is recommended that the patient undergo a double diagnostic block paradigm prior to radiofrequency thermocoagulation, as this is the standard of care.
Appeal type: Medical Necessity
Decision: Overturned

The enrollee is requesting reimbursement for residential treatment center (RTC) level of care. He first started to smoke marijuana at a young age and smokes daily. He also started to use alcohol and consumes six to ten ounces of hard liquor on a daily basis. The enrollee used amphetamines and cocaine, four times intranasally. He had previous outpatient treatment for two months. The enrollee has an inconsistent appetite, unless he smokes marijuana and a sporadic sleep pattern. He had self-injurious behaviors during his teenage years, when he superficially cut himself once because of overwhelming feelings. He reports driving under the influence (DUI), lying, stealing and using substances at work. He has anxiety and loss of pleasure in previous activities. He denies feeling helpless and hopeless, suicidal/homicidal ideation, auditory verbal hallucinations or paranoia.  Mental status examination at the time of admission indicated the enrollee was alert and oriented, anxious and easily distracted. Admission diagnoses included amphetamine use disorder, severe; amphetamine withdrawal; alcohol use disorder, severe; alcohol withdrawal without perceptual disturbance; cannabis use disorder; cannabis dependence and withdrawal; unspecified anxiety disorder; unspecified depressive disorder; and post-traumatic stress disorder (PTSD). Review of the record supports the RTC level of care for two days. The patients Clinical Opiate Withdrawal Scale COWS was indicative of moderate withdrawal. The patient has a long history of substance use and uses alcohol daily.  His clinical opiate withdrawal scale score was consistent with severe alcohol withdrawal. After initiation of the lorazepam taper his scores dropped to moderate withdrawal.  The enrollee participated in all required activities and groups, including family therapy sessions with his father. The Level of Care Utilization System (LOCUS), developed by the American Association of Community Psychiatrists, is a level of care assessment tool widely used by clinicians throughout the country to support accurate level of care recommendations. This tool was used in this review. The enrollee demonstrates willingness to change. The enrollees composite LOCUS score correlates with medically monitored non-residential services. The enrollee had completed a lorazepam taper and was appropriate to transition to a lesser level of care for the dates in question following the initial two days.Final Result: The reviewer determined that the requested service is partially medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 56-year-old female enrollee has requested authorization and coverage for a shower bench for treatment of the enrollees lower extremity paraplegia.  Findings:  The physician reviewer found that spinal cord injury can result in significant functional impairments with respect to basic activities of daily living (McKinley, et al). These impairments can require various durable medical equipment devices so that these basic activities of daily living can be accomplished. A shower bench has been requested, but the patient is already reported to have a shower bench per a rehabilitation medicine clinic note. Further, there is no documentation provided to indicate that the current shower bench is dysfunctional or in disrepair. In the absence of medical rationale to support the necessity of a replacement shower bench, the requested equipment is not medically necessary based on the records forwarded for review.
Appeal type: Experimental/Investigational
Decision: Upheld

A 55-year-old male enrollee requested authorization and coverage of ongoing cancer treatment. The Health Plan denied the request indicating that the requested therapy is considered investigational for treatment of the enrollees colon cancer.Three physician reviewers performed an experimental/investigational Independent Medical Review. All three physician reviewers concluded that the requested therapy is not likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy. Because all three physician reviewers concluded that the requested therapy is not likely to be more beneficial for the treatment of the enrollee's medical condition than any available standard therapy, the Health Plans denial has been upheld.