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

A 67-year-old male enrollee has requested spinal fusion surgery at L2-L3 (CPT code 22633) for treatment of his degenerative disc disease. Findings:  The physician reviewer found that based on the records provided for review, it is not medically necessary for this patient to undergo spinal fusion at the L2-3 level as proposed by the provider. There is an absence of flexion extension views demonstrating instability localized to this level. In addition, there is documentation of multilevel intervertebral disc and facet joint changes, as well as a synovial cyst at the L5-S1 facet joint. There is an emphasis on multiple pain generators by the providers including the SI joint, as well as multiple levels of the lumbosacral spine. The records support a diagnosis of chronic regional pain syndrome. However, this diagnosis lacks the specificity that supports the requested localized surgical intervention. There is no documentation of a lumbosacral radiculopathy and the patient does not require localized treatment of foraminal or central spinal stenosis based upon neurological symptoms. Given the lack of specificity in the patients anatomical studies, lack of confirmation of the patients pain generator, and lack of instability demonstrated on flexion extension films, the requested surgery is not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for MasterGraft Filler for treatment of his severe stenosis and neurological deficits with myelopathy. Findings: The physician reviewer has found that the request for MasterGraft Filler has not been established as medically necessary for treatment of the patients medical condition. The use of MasterGraft bone void filler is to be gently packed into bony voids or gaps of the skeletal system. These defects may be surgically created through osseous defects or osseous defects created from traumatic injury to the bone. However, the use of the MasterGraft bone void filler remains controversial and is not the standard of care. There is a lack of peer-reviewed literature supporting its use in this clinical setting. Given the lack of support in the peer-reviewed literature, the requested service is not medically necessary for treatment of the patients medical condition.  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 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: Upheld

Findings:  The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for alprazolam. Based on data from the American Academy of Sleep Medicine (AASM), alprazolam is not recommended as a first-line medication in the treatment of insomnia in patients over 65 years of age (Sateia, et al.; Edinger, et al.). The records provided for review indicate that this patient has been treated with alprazolam for 30 years for a diagnosis of insomnia. This suggests that the patients insomnia has not been appropriately evaluated and treated. In addition, the patients lengthy treatment with alprazolam does not support continued treatment with this medication. There is a lack of documentation that the patient has been thoroughly evaluated by a sleep specialist. Furthermore, this patient is taking other medications that can cause severe side effects when taken with alprazolam. The patients letter and his records support a likely diagnosis of sleep maintenance insomnia. Patients with sleep maintenance insomnia are evaluated and treated for any underlying causes such as sleep apnea, and cognitive behavioral therapy provides an effective long-term treatment. There is a lack of evidence that this patient has been treated with cognitive behavioral therapy. Given these findings, the requested alprazolam is not medically necessary 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 internal medicine with subspecialty certification in sleep medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Epclusa for 12 weeks. Findings:  The physician reviewer found that according to 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 life expectancy less than 12 months due to non-liver-related conditions. The guidelines state that all patients should be treated, regardless of fibrosis stage, and advanced fibrosis is not a requirement for treatment.  Additionally, the patient should be considered treatment-naive per the guidelines, as he failed interferon, rather than PEG-interferon with ribavirin.  Per the guidelines, Epclusa for 12 weeks is recommended as first-line therapy for treatment-naive, genotype 3 patients. The current guidelines cite data showing reduced survival with delayed treatment. For these reasons, Epclusa for 12 weeks is medically necessary for the treatment of this patients hepatitis C infection. Final Result: The reviewer determined that the the requested medication regimen 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 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: Experimental/Investigational
Decision: Upheld

A 43-year-old female enrollee has requested Botox injections for treatment of her migraine headaches. Findings:  Three physician reviewers found that although Botox therapy has been shown to be helpful in select patients with migraine, its use is typically reserved for treatment after the patient has failed at least one agent from several classes of prophylactic medications (anti-convulsants (such as Topamax), antidepressants (such as Elavil and Trazodone), and/or cardiovascular agents (such as Inderal and verapamil)). In this patients case, the submitted documentation does not establish that she has had any trials of the many prophylactic agents available. Since the use of Botox as first line therapy is not supported by the scientific evidence, this patient does not meet appropriateness criteria for the use of Botox for treatment of her migraines.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested breast tomosynthesis for evaluation of her medical condition.  Findings:  Two physician reviewers found that despite the lack of long-term studies proving an increased survival rate when tomosynthesis has been used as part of screening mammography the American College of Radiology (ACR) has urged the technique be removed from the investigational category due to the advantages it brings radiologists interpreting mammograms. This new tomographic technique allows the radiologist to separate dense glandular elements from underlying mass and architectural distortion resulting in a decrease in callbacks and biopsies and increase in detection of small cancers. In this case, the patient has a history of prior lumpectomy with a likelihood of architectural distortion. Tomosynthesis was indicated as it provides a higher accuracy of interpretation. Thus, breast tomosynthesis was likely of greater benefit to the patient than had the exam been done with two-dimensional imaging alone. Final Result: Two 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 parent of a 10-year-old male enrollee has requested upgraded Nucleus 24 Freedom bilateral sound processors for treatment of his mixed conductive and sensorineural hearing loss.  Findings:  The physician reviewer found that the submitted clinical evidence does not demonstrate that the patients ESPrit 3G processors were non-functioning at the time he received the Nucleus 23 Freedom processors. While there has been some improvement in the patients performance with the Freedom processors, the changes are small, and did not result in a dramatic difference in the patients functional status. Based upon the evidence provided, there was not a compelling need to switch to the Nucleus Freedom processors.
Appeal type: Medical Necessity
Decision: Upheld

A 57-year-old female enrollee requested authorization and coverage for treatment with herceptin.  The health plan has denied this request indicating that herceptin is not medically necessary for treatment of the enrollees breast cancer.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer upheld the health plans denial on the basis that the requested treatment is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

A 19-year-old female enrollee has requested an audiology processing examination for evaluation and treatment of her progressive hearing loss. Findings:  The physician reviewer found that this patient has been thoroughly evaluated with a complete work-up. Given her previous history of learning disability in school, she may suffer from central auditory processing disorder (CAPD). In the medical literature, Chermak and colleagues noted that CAPD has been found to overlap significantly with other central disorders. This patient shows no evidence of acute neurological problems despite adequate neurological evaluation. Thus, further evaluation for CAPD is not warranted at this time. All told, the requested referral and evaluation have not been established as medically necessary for management of this patients condition.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a 10-year-old female has requested  attachment therapy and functional magnetic resonance imaging for evaluation and treatment of her post-traumatic stress disorder, attention deficit/hyperactivity disorder, alcohol effects syndrome, and developmental delay.  Findings:  The physician reviewer found that the current medical evidence does not support the requested services in this patients case.  Current practice guidelines do not endorse functional magnetic resonance imaging in this clinical setting.  In terms of clinical application, the efficacy of functional magnetic resonance imaging has not been established in this setting.   Data yielded from the requested imaging is not likely to impact treatment decisions, as particular findings do not yet correlate with specific interventions.  Thus, the requested functional magnetic resonance imaging is not medically necessary.  This patient requires treatment for her post-traumatic stress disorder and likely reactive attachment disorder.  Conceptually, such therapy is based on abreaction, context and correction, along with the establishment of parental figure consistency in a safe community setting.  This process can take years.  Per the current medical literature, the particular modality of attachment therapy is not supported as an evidence-based therapeutic intervention.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/ Case Summary:  The enrollees parent requested authorization and coverage for 30 hours/week of direct one-on-one and 15 hours/week of direct supervision applied behavioral analysis (ABA) services.  Findings:  The physician reviewer found that the enrollee has autism and displays behaviors, such as aggression and screaming. Vineland scores were low in areas of communication, daily living skills, socialization, motor skills, and adaptive behavior composite. A treatment plan update indicates the domains addressed with ABA therapy include social skills, communication, self-help, behavioral management, play, and parent training. The therapy has been effective in reducing problem behaviors and has increased replacement behavior/mitigating skill deficits.  However, she continued to demonstrate difficulties in communication, socialization, self-help skills, play and behavior management. The BCBA indicates that 30 hours per week of intensive one-to-one ABA treatment is medically necessary for the enrollee to reach her goals since she is still low in all domain areas and under the last ABA authorization period, she met approximately 65% of the recommended goals written for 30 hours per week of treatment. According to the medical literature, ABA therapy is a behavioral intervention used to treat autism spectrum disorders (ASD). Typical ABA programs are 25 to 40 hours per week. ABA is effective in improving communication, social skills, and management of problem behavior for children with ASD. ABA treatment is generally appropriate to continue until such time that the enrollee has reached their maximum attainable goals or until no further progress is seen.  Decreasing the recommended frequency of therapy would not be appropriate, as doing so may result in a significant decline in skills achieved. Vineland Adaptive Behavior Scale scores indicate the enrollees current adaptive level was low. Baseline skills including receptive, expressive and written were low.  Scores were low with personal and community and moderately low with domestic.  The fine motor skills adaptive level was moderately low. The enrollee had made progress in communication and self-help but continued to demonstrate difficulties in communication, socialization, self-help skills, play, and behavior management.  Final Result: The reviewer determined the requested service is medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in psychiatry and 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 49-year-old female enrollee has requested for a PET scan for evaluation of her breast cancer. Findings:  The physician reviewer found that there are multiple studies in the peer-reviewed literature have shown that PET/CT scans are clinically effective in monitoring response to chemotherapy in those patients with metastatic breast cancer. Schwarz and colleagues found that PET scans could predict response to treatment following the first cycle of chemotherapy. Rosen and colleagues reported that PET/CT is particularly useful in determining response to therapy. Smith and colleagues found that PET imaging can predict response of metastatic breast cancer to chemotherapy, and Couturier and colleagues found that PET studies done after three cycles of chemotherapy are useful for monitoring response to chemotherapy in metastatic breast cancer.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Saxenda. Garvey and colleagues noted that, Obesity is a complex, adiposity-based chronic disease, where management targets both weight-related complications and adiposity to improve overall health and quality of life. The authors noted that the addition of pharmacotherapy produces greater weight loss and weight loss maintenance compared with lifestyle therapy alone. The U.S. Food and Drug Administration (FDA) has approved Saxenda for the treatment of obesity. Authors noted, Liraglutide treatment was associated with reductions in cardiometabolic risk factors, including waist circumference, blood pressure, and inflammatory markers. Modest improvements in fasting lipid levels were also observed, although the clinical relevance of these improvements is uncertain. Furthermore, patients in the liraglutide group had greater reductions in fasting and postprandial glycemic variables and more improvement with respect to beta-cell function and insulin sensitivity than did the placebo group. The combination of weight loss and improved glycemic control probably contributed to the observed reductions in the prevalence of prediabetes and the delayed onset of type 2 diabetes. In this patients case, she was successfully treated with Saxenda in the past. The medical evidence supports the requested medication in this clinical setting. Therefore, Saxenda 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 internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism. 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 51-year-old female enrollee requested hydrotherapy for medical treatment of her psoriatic arthritis. Findings:  The physician reviewer found that the records do not establish that a formal aquatic therapy program is medically necessary. Formal aquatic therapy, as opposed to generalized water-based exercise, is medically necessary only for patients who require therapy in a partially body weight unloaded environment. There are no documented clinical findings or notes indicating her impairments, functional deficits, and specific therapy goals to establish that formal therapy is necessary. All told, the request for hydrotherapy with or without an exercise coach is not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 55-year-old female enrollee has requested authorization and coverage for a CT full body scan, a CT spinal cord scan, an MRI full body scan, and an MRI spinal cord scan for evaluation of the enrollee, who has a history of migraine. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested diagnostic procedures in this patients case.  She has chronic migraine with comorbid anxiety and depression.  Per the submitted medical records, the patients neurological examination has been normal.  The current medical evidence does not support the requested diagnostic procedures in this patients case.  Per the medical literature, the diagnostic yield for brain imaging in patients with a history of headache consistent with migraine, normal examination, and no red flag features is very low.  As noted by Tsushima and Endo, MRI evaluation is not likely to be beneficial for the evaluation of patients with chronic or recurrent headache and normal neurologic findings.  The medical records do not demonstrate the medical necessity whole body imaging or spinal imaging in this clinical setting.  All told, the requested CT full body scan, CT spinal cord scan, MRI full body scan, and MRI spinal cord scan are not medically indicated for the evaluation of this patient.
Appeal type: Medical Necessity
Decision: Overturned

A 28-year-old male has requested coverage for a power wheelchair for treatment of his spastic hemiparesis. Findings:  The physician reviewer found that the submitted documentation demonstrates the medical necessity of the requested equipment in this patients case.  The determination of medical necessity of a power wheelchair is based upon specific criteria.  These criteria include whether the patient is unable to ambulate independently with use of an assistive device, and whether the patient does not have sufficient upper extremity function to propel a manual wheelchair.  Additional factors include if the patient has demonstrated the ability and willingness to safely operate a power-operated vehicle, whether a power wheelchair is needed to perform in-home mobility-related activities of daily living, and if the patients residence will accommodate such a device.  In this patients case, the clinical records support the medical necessity of the prescribed power wheelchair.  All told, the requested power wheelchair is medically indicated in this clinical setting.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested  residential treatment center (RTC) services for treatment of her medical condition.  Findings:  The physician reviewer found that there is a lack of clinical evidence to suggest that the patient would not respond to treatment at a less intensive level of care.  She no longer required supervision in a highly structured setting to prevent eating disorder behaviors. In addition, no new problems had arisen and there was no evidence to suggest that re-entry into the community would lead to decompensation that would necessitate readmission to a residential setting. Although she continued to struggle with issues of body image, anxiety, depression, and self-esteem, and required ongoing treatment, this treatment did not require the 24-hour supervised setting of residential level of care. Moreover, the records do not support readmission to RTC level of care. Thus, RTC services and resumption of RTC services were not and are not medically necessary for treatment of this patients eating disorder.  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.