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

A 54-year-old male enrollee has requested skilled nursing facility (SNF) services or in the alternative, outpatient physical, occupational, and speech therapies for treatment of his medical condition status post multiple ischemic strokes. Findings:  The physician reviewer found that with regard to the skilled nursing visits from the date of service at issue onward, the patient did not have ongoing medical issues that required regular monitoring by skilled nursing professionals. The services provided during this period included assistance with nutrition and medications, bowel and bladder incontinence care, supervision due to impulsivity, and physical assistance for activities of daily living and basic mobility tasks. As noted above, these services are based on custodial needs. Thus, the patients care could have been safely provided in a custodial setting without scheduled nursing visits. Similarly, the evidence does not support continuation of skilled nursing visits at this time. Concerning the medical necessity of outpatient occupational therapy, speech therapy, and physical therapy, based on the patients documented deficits and level of functioning, each modality is medically necessary at a frequency of once a week. Such services are indicated to assess the patients function, adjust home programs as necessary, and make assessments and recommendations regarding appropriate supervision and assistance needs, as well as to train caregivers as needed.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollees parent has requested authorization and coverage for RELiZORB in-line cartridges containing digestive enzymes. This patient presents with a history of cystic fibrosis with exocrine pancreatic insufficiency, failure to thrive, gastroesophageal reflux disease (GERD), poor weight gain, and milk protein allergy. The patients provider has recommended treatment with RELiZORB pancreatic enzyme replacement therapy. Cystic fibrosis patients with pancreatic insufficiency require solid pancreatic enzyme replacements. In this case, the patients length has been less than 5%, which is consistent with poor caloric absorption. RELiZORB has been shown to be effective in facilitating nutrient absorption in this patient population (Stevens, et al.; Freedman, et al.). In clinical trials, RELiZORB was also demonstrated to be safe, well tolerated, and effective in improving pulmonary and inflammatory status. Given this support, the requested RELiZORB in-line cartridges containing digestive enzymes are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Findings:  Two of the three physician reviewers found the requested RELiZORB in-line cartridges containing digestive enzymes are 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 medication is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewer 1 is board certified in pediatrics with subspecialty certification in pediatric gastroenterology and is actively practicing. Physician reviewer 2 is board certified in pediatrics with subspecialty certification in pediatric gastroenterology and is actively practicing. Physician reviewer 3 is board certified in pediatrics with subspecialty certifications in medical toxicology and pediatric pulmonology 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: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for magnetic resonance imaging (MRI) of the right shoulder. Findings: Per the American College of Radiology (ACR), MRI can aid in detecting extra-articular abnormalities including osseous and soft-tissue findings that may predispose to or be the result of shoulder impingement. A study concluded that rotator cuff pathology accounts for most presentations of shoulder pain to primary care clinics. The authors noted that history and physical examination are important for excluding other causes of shoulder pain, while imaging assists in confirming the diagnosis and defining the severity of the abnormality. The ACR criteria state that MRI is considered the gold standard in the evaluation of the shoulder for entities involving the glenoid labrum and rotator cuff given its excellent depiction of soft tissue structure and evaluating a shoulder that failed to show pathology on x-ray. In this case, the patient is being treated for pain in the right shoulder. The patients progress notes indicate that their right shoulder pain is likely attributed to an accident. However, detailed documentation is not evident regarding trial and failure of recent, reasonable, and comprehensive less invasive conservative care measures. In addition, the records do not include an x-ray report that failed to show pathology. Given these considerations, the requested MRI of the right shoulder is not medically necessary for this patient. Final Result: The reviewer determined that the requested services are 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 orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 26-year-old male enrollee has requested adult substance abuse subacute/RTC rehabilitation services for the treatment of his substance use disorder. Findings:  The physician reviewer found that the submitted evidence reveals that this patients relationships, education, and job performance have all been affected by his substance use and alcohol dependence. The patient has endangered himself and others by driving while intoxicated. The patient has been in treatment multiple times, including outpatient rehabilitation over the past nine years, inpatient treatment a couple of years ago for two months, and has attended alcoholics anonymous with only short periods of abstinence. The records reflect that the patient made good progress during his treatment stay, in both individual and group settings, and that his medications were actively evaluated and titrated up until the day before discharge. The patient reported feeling that he was at a point of being motivated to change at the time of this admission. The providers notes indicate the patients triggers for drinking were addressed in an effort to prevent relapse and a detailed after-care plan was established. At the time of discharge, the question of ADHD had not been completely evaluated but several other factors contributing to the patients dependence were addressed. Given the patients history of a cycle of repeated dependence upon alcohol that had resulted in serious consequences, as well as his failure to respond to treatment at a less intensive level of care, treatment in a 24-hour subacute residential setting was appropriate and indicated during the period at issue.
Appeal type: Medical Necessity
Decision: Upheld

An enrollee has requested authorization and coverage for trigger point injections. The submitted documentation does not support that the requested trigger point injections are medically necessary at this time. Trigger point injections may be considered for treatment of patients with myofascial pain as part of a multimodal approach to pain management. In this case, the submitted documentation does not include physical exam findings consistent with myofascial trigger points. While the providers notes make reference to tenderness to palpation in various muscle groups, there is no documentation of any palpable, tense bands of skeletal muscle fibers that elicit a twitch response when palpated, with referral of concordant pain. In addition, the providers notes indicate that it is their plan to refer the patient to physical therapy for conservative care prior to considering further interventional treatment, with follow-up scheduled one month later. While the submitted records show that the patient had an earlier series of physical therapy appointments, there is no documentation that the patient attended physical therapy pursuant to the providers most recent referral. Furthermore, while records reflect that the patient received multiple prior trigger point injections this year, there is no documentation of the patients response to previous injections, including any change in pain-free range of motion, improvement in function, or reduced need for medications. Under these circumstances, the requested trigger point injections are not medically necessary to treat the patients medical condition at this time.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 anesthesiology, with subspecialty certification in pain medicine, and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for lumbar/sacral facet joint block at bilateral L4-5. Researchers performed a systematic review of lumbar facet joint injections and medial branch blocks for the treatment of patients with chronic low back pain. The authors found promising data to support the efficacy of medial branch blocks for chronic low back pain deriving from facet joints osteoarthritis. The current American Society of Interventional Pain Physicians (ASIPP) guidelines for lumbar medial branch blocks and facet joint injections state that, The level of evidence is II in selecting patients for facet joint nerve blocks at least three months after onset and failure of conservative management, with strong strength of recommendation for physical examination and clinical assessment. In addition, ASIPP noted that, The level of evidence is II with moderate strength of recommendation for therapeutic lumbar facet joint nerve blocks with inclusion of three relevant randomized controlled trials, with long-term improvement. This patients records document the presence of chronic low back axial pain. There are lumbar MRI findings of degenerative disc and joint disease at the L4-5 level. Physical examination demonstrated positive facet joint challenge with normal neurological examination results. The patient has failed conservative care with physical therapy and non-steroidal anti-inflammatory drug (NSAID) therapy, and epidural steroid injections have become less effective over time. Based on current guidelines, lumbar medial branch blocks are indicated to confirm and treat this patients lumbar facet joint related back pain. Therefore, the requested lumbar/sacral facet joint block at bilateral L4-5 is medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in anesthesiology with subspecialty certification in pain 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 patient has had long-standing migraine headaches that respond to Imitrex. She is using 50mg tablets and indicates she needs more than one tablet per attack. Attacks remain frequent and may last days per the submitted records. Several prior preventatives have been used, apparently without much success. The patient has requested authorization and coverage for 27 Imitrex tablets per month. The Health Plan has determined the requested prescription is not medically necessary for treatment of the patients migraine headaches.The patients migraines are disabling and acute abortive therapy has been effective for this patient. However, she continues to have frequent headaches and does not appear to have been on any anti-convulsant category of prevention, such as Depakote, Topamax or Neurontin. Further preventive care is indicated with ongoing neurologic input. In addition, the patient is on hormonal medication that sometimes worsens headaches and its discontinuation should be considered. Moreover, she is using 50mg tablets of Imitrex and may have a better headache free response to 100mg tablets, which may reduce the number of times she needs to be retreated and the number of tablets needed per month. In any event, there is no medical justification for 27 Imitrex tablets per month. Therefore, I have determined the requested prescription is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested inpatient mental health services for treatment of her behavioral health condition.  Findings:  The physician reviewer found that the documentation submitted for review does not support the medical necessity of the inpatient mental health services in dispute. Initially, the patient was anxious, angry and depressed. Despite her distress, there was no mention of cognitive impairment, psychosis or suicidal ideation. There were no significant medication changes as she continued on quetiapine and sertraline. The records do not include a thorough mental status examination and there was no assessment of the patients risk for suicide. There was no treatment plan. There was no interpretative summary articulating the need for service delivery at the inpatient setting as opposed to a less restrictive level of care. In sum, the record does not demonstrate the presence of an acute psychiatric syndrome or medical crisis. Thus, the inpatient mental health services in dispute were not and are not medically necessary for treatment of the patients behavioral health condition. Final Result: The reviewer determined that the services at issue were not and 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 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for implantation of hypoglossal nerve stimulator Inspire device. Findings:  The physician reviewer found that this patient has a history of obstructive sleep apnea without nasal obstruction. A drug-induced sleep endoscopy (DISE) showed no concentric collapse at velum and primarily anterior posterior collapse. The patient has not been able to tolerate treatment with a continuous positive airway pressure (CPAP) device. The Inspire device is a U.S. Food and Drug Administration (FDA) approved device for the treatment of OSA device (Van de Heyning, et al.; Strollo, et al.; Steffen, et al.). The patient is a candidate for the Inspire device given his intolerance to CPAP, anterior posterior collapse without evidence of concentric collapse, no central apnea, and an apnea/hypopnea index (AHI) of 45.7 events per hour, which is within FDA criteria with more than 15 and 65 or fewer events per hour. Therefore, the requested implantation of hypoglossal nerve stimulator Inspire device is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings:  Two of the three physician reviewers found the requested implantation of hypoglossal nerve stimulator Inspire device is 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 services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewers 1 and 2 are board certified in otolaryngology and are actively practicing. Physician reviewer 3 is board certified in otolaryngology with subspecialty certification in sleep medicine 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: Medical Necessity
Decision: Upheld

The parent of an 8-year-old female enrollee has requested  testing for central auditory processing disorders (CAPD) for evaluation of the enrollees medical condition. Findings:  The physician reviewer found the submitted documentation fails to establish the medical necessity for the requested services. The article by Moore notes that CAPD is ill-defined and interventions appear to have limited effectiveness. The author further opines that children who are poor listeners tend to have a range of cognitive difficulties. Fey and colleagues reviewed the peer-reviewed literature on the efficacy of interventions for school-age children with auditory processing disorder. The authors concluded that the evidence base is too small and weak to provide clear guidance for speech pathologists. Further, the article by Moore and colleagues indicates that listening difficulties in children with normal hearing diagnosed with CAPD is the co-concurrence of other learning disorders. Thus, the article suggests that the CAPD diagnosis may be a symptom of more varied neurodevelopmental disorders. Based on the medical literature cited above and the documentation submitted for review, the requested services are not medically necessary for evaluation of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 10-year-old female enrollee has requested speech therapy for the treatment of the enrollees auditory processing disorder and dyslexia. Findings:  The physician reviewer found that speech and language therapy is medically necessary for treatment of this patients auditory processing deficits. The American Speech-Language-Hearing Association (ASHA) broadly defines central auditory processing as the efficiency and effectiveness by which the central nervous system (CNS) utilizes auditory information. Auditory processing includes the following: sound localization and lateralization, auditory discrimination, auditory pattern recognition, temporal aspects of audition including temporal integration, temporal discrimination, temporal ordering and temporal masking, auditory performance in competing acoustic signals, and auditory performance with degraded acoustic signals. Central auditory processing disorder is then, A deficit in neural processing of auditory stimuli that is not due to higher order language, cognitive, or related factors. Although it may coexist with other disorders, it is not caused by these other disorders. ASHA has emphasized that evaluation must be individualized, with testing based on complaints and symptoms. A wide variety of tests can be utilized to provide an appropriate assessment. Interpretation of such tests should be performed by individuals experienced in the complexities of central auditory processing disorders. Intervention should be implemented as soon as possible following the diagnosis to exploit the plasticity of the central nervous system, maximize successful therapeutic outcomes, and minimize residual functional deficits. This patient has been evaluated multiple times by a variety of specialists using many different assessment tools, revealing auditory processing deficits. Speech and language therapy to address these deficits is therefore medically reasonable and appropriate.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for Nutropin AQ NuSpin. A study noted that human growth hormone and human IGF-1 are treatments for growth hormone deficiency, idiopathic short stature, and primary IGF-1 deficiency in children and adolescents. In this case, the patient has a growth hormone deficiency based on low circulating IGF-1 levels, an abnormally low growth velocity despite recent onset of normal puberty, and abnormally low peak circulating serum peaks of GH concentrations. Based on the records, growth hormone treatment is medically indicated for this patient. Therefore, Nutropin AQ NuSpin 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 pediatrics with sub-specialty certification in pediatric endocrinology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

A 62-year-old male enrollee has requested the Bioness L300 Foot Drop System for the treatment of his incomplete spinal cord injury. Findings:  Two physician reviewers found that there are sufficient data to support a finding that this device stimulates gait close to normal, and has been successful in improving walking speed. In addition, the Bioness System offers synchronization of the stimulation site and timing, and brings the patients walking pattern closer to normal. This helps avoid hip hiking and should reduce back and hip pain as well. Alternate treatment would be use of an ankle-foot-orthotic (AFO). While an AFO can allow the patient to walk without falling, the ankle will tend to become stiff and the walking pattern is not likely to improve. All told, the Bioness System is superior to any other device available in this setting.