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

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for occipital nerve block injections. Occipital nerve blocks are considered the standard of care for this patients diagnosis of occipital neuralgia. Researchers found that occipital nerve block with a local anaesthetic and corticosteroids provides a safe, simple, and effective treatment method for the patient with medically-refractory occipital neuralgia. The records provided for review document that this patient presents with new onset chronic daily headache after laminectomy. The provider reports the patient has failed two standard medications for this condition, gabapentin and nortriptyline. In addition, the records report the patient experienced an improvement in symptoms with occipital nerve blocks. Given this support, the occipital nerve block injections were and are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: Two of the three reviewers determined that the services at issue were and 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:  One reviewer is board certified in neurology with subspecialty certification in in neuromuscular medicine and is actively practicing. One Reviewer is board certified in neurology and is actively practicing.  One Reviewer is board certified in neurology with subspecialty certification in sleep medicine and is 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

Nature of Statutory Criteria/Case Summary:  An enrollee has requested 24-hour skilled nursing facility care for treatment of his back pain. The physician review found that based on the clinical documentation submitted for review, the medical necessity for 24-hour skilled nursing facility care has not been established. In this case, the patient has had years of low back pain and reduced level of social functioning. Based on his physical examination, he does not have any significant impairment of functional mobility or self-care. The documentation submitted for review does not demonstrate that intensive inpatient level physical or occupational therapy is clinically indicated. Moreover, the records submitted do not establish the medical necessity for 24-hour nursing. The patient has assistance for transportation, meals, and laundry. There is no evidence to support inpatient rehabilitation, inpatient medical care, or 24-hour custodial care. For the reasons provided, 24-hour skilled nursing facility care is not medically necessary for treatment of the patients medical condition. 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 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 Hyalgan or Supartz. Findings: This patient presents with a history of right knee pain due to progressive degenerative changes as demonstrated on magnetic resonance imaging (MRI). Treatment has included an unloader brace, Naproxen, topical diclofenac, Norco, and ibuprofen. The provider has recommended treatment with viscosupplementation with Hyalgan or Supartz injections of the right knee for osteoarthritis. Evidence from systematic reviews and randomized controlled trials indicate that although viscosupplementation may relieve knee pain in some patients with osteoarthritis, data has not established which patients will benefit. Guidelines from the American Academy of Orthopedic Surgeons (AAOS) indicate that the data on safety and efficacy of viscosupplementation remain inconclusive. As such, the AAOS does not currently recommend viscosupplementation as routine treatment for osteoarthritis of the knees. Viscosupplementation is reserved for patients with a history of lasting benefit from prior injections and in cases where the remaining options are limited. In this patients clinical setting, the remaining treatment options are limited. In this clinical setting, treatment with either Hyalgan or Supartz is appropriate. Given these findings, the requested Hyalgan or Supartz 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 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: Experimental/Investigational
Decision: Upheld

A 61-year-old female enrollee requested authorization and coverage of a gastric bypass with duodenal switch. The Health Plan denied the request indicating that the requested procedure is considered experimental for treatment of the enrollees morbid obesity.Three physician reviewers performed an experimental/investigational 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 procedure is not likely to be more beneficial for the treatment of your 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: An enrollee has requested authorization and coverage for Epclusa 400-100 mg tablet for treatment of the enrollees chronic hepatitis C virus (HCV) genotype 3. Findings:  The physician reviewer found that According to joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with life expectancy less than 12 months due to non-liver-related conditions. This applies in all cases, regardless of fibrosis stage. Per the guidelines, Epclusa is recommended as a first-line regimen for non-cirrhotic treatment-naive genotype 3 patients. This is based on the ASTRAL-3 trial for Epclusa, which showed a high cure rate of 98%. The AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, the requested treatment with Epclusa 400-100 mg tablet is supported as medically necessary for the treatment of this patients hepatitis C infection. 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 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

The patient is a 50-year-old man with a history of plantar fasciitis, Achilles tendonitis, and calcaneal bone spurs. He underwent extracorporeal shock wave therapy (ESWT) in May 2005.  He is requesting reimbursement for the procedure. The Health Plan has denied the patients request on the basis ESWT was not medically necessary for treatment of the patients condition.There have been no long-term, prospective studies published that support the benefits and effectiveness of ESWT, and the long-term risks of the procedure are unknown. There is no proven benefit for ESWT over standard care therapies. As such, there was no medical justification for ESWT for treatment of the patients plantar fasciitis and Achilles tendonitis. Accordingly, I have determined the procedure at issue was not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Urgent Care
Decision: Overturned

A 41-year-old female enrollee has requested reimbursement for surgical services performed on an urgent basis.  Findings:  The physician reviewer found that this patient had been experiencing ongoing symptoms for several years and her symptoms were worsening. She had been seen by multiple in-plan physicians without improvement in her symptoms. A surgical treatment plan was not in place. As the patients condition progressed and worsened, she consulted a non-plan surgeon who diagnosed her condition and offered her appropriate surgical treatment. A prudent layperson with progressive and worsening symptoms due to a pineal cyst would have believed she was experiencing an urgent medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The parent of an 11-year-old male enrollee has requested occupational therapy for treatment of the enrollees multiple medical conditions.  Findings:  The physician reviewer found that review of the submitted documentation demonstrates that the patient has multiple psychiatric, behavioral, educational, and social problems. Occupational therapy testing, utilizing the well-accepted Bruininks-Oseretsky Test of Motor Proficiency, indicated an acute need for occupational therapy intervention. The usual and customarily practice in the medical community would be to refer this patient for occupational therapy.  There is sufficient medical evidence of the efficacy of occupational therapy in children who demonstrate such deficiencies in formal testing. The purpose of occupational therapy is to improve the patients abilities to adapt and function in his/her activities of daily living.  With the degree of sensory processing and motor impairment that this patient has, it is medically necessary for him to receive occupational therapy services. Sensory integration techniques enable the occupational therapist to assist patients in developing the ability to integrate into normal motor and personal-social patterns, in order to function appropriately with their peers (Schaaf and Miller). The peer reviewed medical literature demonstrates that sensory integrative programs for improving sensory-motor function in developmentally delayed children have been successful (Miller, et al.). Additionally, patients who have been treated by an occupational therapist, utilizing sensory integration techniques, have shown improvements in behavioral patterns (Roberts, et al.). Therefore, it is medically necessary that the patient receive the requested occupational therapy services.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for partial hospital program (PHP) services. The American Association of Community Psychiatrists Level of Care Utilization System (LOCUS) provides a reliable framework for determining the appropriate level of care for adults needing mental health treatment. Using LOCUS, providers score patients on a scale of 1-5 using a six-pronged Dimensional Rating System. The six dimensions include: (1) risk of harm; (2) functional status; (3) medical, addictive and psychiatric comorbidity; (4) recovery environment (a. stressors and b. supports); (5) treatment and recovery history; and (6) engagement. The composite score is then used to determine the level of care needed. With regard to risk of harm, the records support a score of 3. The patient had a moderate risk of harm, due to intermittent suicidal ideation. In terms of functional status, the records support a score of 3. The documentation moderate impairment due to significant eating disorder.With regard to comorbidity, the records support a score of 3. The records documented the presence of tachycardia and orthostatic hypotension as a result of food restricting. She is at high risk of metabolic abnormalities and has lost weight since admission to PHP.In terms of level of stress of the recovery environment, the records support a score of 3. The patient had a mildly stressful environment due to living with a roommate who is recovering from an eating disorder, but reported a supportive family. With regard to level of support of the recovery environment, the records support a score of 2 as the patient had a supportive recovery environment. In terms of resiliency and treatment history, the records support a score of 4. The patient had poor response to treatment, reporting several admissions at varying levels of care over the past several years.With regard to treatment acceptance and engagement, the records support a score of 3. The patient had been adherent with treatment although she struggled with her eating plan. Thus, the patient had a total score of 21. In this case, the recommended level of care is Level 4, medically monitored non-residential care. Therefore, PHP services were and are medically necessary for the treatment of this patient.Final Result: The reviewer determined that the services at issue were and 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 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 female enrollee requested 10-12 sessions of acupuncture services for medical treatment of her back pain. Findings:  The physician reviewer found without documentation of how a condition began, description of subjective complaints, inclusion of the examination findings, positive orthopedic findings, and functional-motor-sensory deficits to be addressed by the care requested, additional acupuncture sessions are not indicated. Also, as the patient underwent prior acupuncture, the number of completed sessions and the benefits obtained, should be included in the request for acupuncture, in order to support an indication for additional care. In sum, the requested 10-12 sessions of acupuncture services do not meet the clinical criteria for medical necessity.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/ Case Summary:  The enrollee requested coverage for Radicava infusions. The enrollee has been diagnosed with the neurodegenerative disorder amyotrophic lateral sclerosis. He has been taking the medications riluzole, baclofen, and gabapentin. His physician has prescribed Radicava infusions. Radicava is Food and Drug Administration (FDA) - approved to slow the progression of amyotrophic lateral sclerosis. It is approved for all patients with amyotrophic lateral sclerosis and not just those meeting certain functional criteria. According to the FDA, the pivotal medical trial on which approval for this medication was based had strict enrollment criteria for the subjects, requiring that amyotrophic lateral sclerosis be recently diagnosed and relatively mild in order to maximize the likelihood of detecting the drugs effect on progression in a short period of time. The medical trial was designed to be applicable to all patients with amyotrophic lateral sclerosis, and Radicava is approved for all patients with amyotrophic lateral sclerosis. Radicava is medically necessary for this enrollee. Final Result: The reviewer determined that the requested service is medically necessary for the treatment of the enrollees medical condition.Credentials/Qualifications: The physician reviewer is board certified in neurology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

A 45-year-old female enrollee has requested authorization and coverage for rituximab injection. The Health Plan has denied this request indicating that the requested medication is considered investigational for treatment of the enrollees Sjogrens syndrome.  Findings:  Two physician reviewers found that the patient has symptoms consistent with Sjogrens syndrome.  A biopsy confirmed Sjogrens syndrome and a small fiber neuropathy.  The patient has been diagnosed with fibromyalgia associated with Vitamin D deficiency and hyperparathyroidism.  Per the submitted documentation, she has been treated with prednisone, hydroxychloroquine and methotrexate, without a therapeutic response.  The provider reported that the patients treatment has included Cymbalta and other antidepressants, although further details were not provided.  The patient continues to be symptomatic.  She has requested authorization and coverage for rituximab injection.  The Health Plan has denied this request and reported that the requested medication is investigational for the treatment of this patient.  The patient has appealed this denial.  In this case, the requested rituximab injection is likely to be more efficacious than other available treatment options. She has failed steroids, methotrexate and hydroxychloroquine.  The current medical evidence supports the requested rituximab injection in this patients case. Ramos-Casals and colleagues published a systematic review and reported that several small trials with rituximab have had some success.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for skilled nursing facility (SNF) services. At the time of admission, the patient required skilled rehabilitation services to improve his level of function. There were no skilled nursing needs. Subsequently, the patient did not require any skilled nursing or rehabilitation services on a daily basis as. He was not expected to make measurable gains within a reasonable and predictable timeframe and he did not require skilled therapy to prevent deterioration with mobility or activities of daily living. The patient did not require skilled therapy to establish a safe and effective maintenance program. Subsequently, the patient did not have any parenteral medications, complex wound care or nutrition given via a feeding tube. He received skilled care and he improved. By the date of denial, his function had plateaued and he did not require any further inpatient skilled rehabilitation services. Therefore, the SNF services provided were not medically necessary for treatment of this patient. Final Result: The reviewer determined that the services at issue were not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in internal medicine with expertise in skilled nursing facilities 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 reimbursement for single photon emission tomography computed (SPECT) scan. The Health Plan has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees melanoma.Findings:  Sentinel lymph node excision (SLNE) is considered the most sensitive and specific staging test for the detection of micro-metastatic melanoma in regional lymph nodes. Melanoma metastasizes early into regional lymph nodes. Thus, SLNE is an important diagnostic and potentially therapeutic procedure for patients with melanoma. The histological status of the sentinel lymph node (SLN) is the most relevant prognostic factor for overall survival in patients with melanoma, independent of primary tumor thickness. However, SLNE has a high false negative rate of up to 44%. The current gold standard for SLN detection and targeted extirpation is preoperative lymphoscintigraphy. As such, the SPECT technique could help overcome these difficulties by providing additional anatomical information to the provider. Therefore, the preoperative three dimensional SLN mapping by means of SPECT was beneficial in this patients case. In addition, the National Comprehensive Cancer Network (NCCN) guidelines noted that, In selected cases, especially the head and neck and pelvic regions, SPECT-CT imaging may be performed as an adjunct to planar imaging to better define the anatomic location of the sentinel node(s).  Based on recent recommendations in the guidelines as well as the medical data, SPECT scan was likely to have been more effective over other modalities for the evaluation of this patients medical condition. Final Result: All three reviewers have determined 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.