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

Nature of Statutory Criteria/Case Summary: The parent an enrollee has requested authorization and coverage for clinical speech therapy in addition to speech-language pathology services provided at school. The Health Plan has denied this request indicating that the requested therapy is not medically necessary for treatment of the enrollees neuromuscular disorder, hypomyelination with atrophy of the basal ganglia and cerebellum.At issue in this case is whether the requested clinical speech therapy in addition to speech-language pathology services provided at school is medically necessary for treatment of the enrollees medical condition.Fried-Oken and colleagues describe that regular re-evaluations and continual treatment are essential for individuals with neurodegenerative diseases who use AAC devices. As the disease progresses, the author notes that `strategies will change over time and use multiple modalities to capitalize on patients' strengths`. Fried-Oken and colleagues also note, `Patients can maintain effective, functional communication with AAC supports. Individualized communication systems can be implemented ensuring patients remain active participants in daily activities`.Hustad and colleagues explain the difference between the speech therapy typically provided in school, compared with that provided by a speech therapist who is an expert with AAC devices. Interventions provided to the children by general speech-language pathologists (who were not AAC experts) tended to be broader in scope, focusing on reducing underlying impairments. Interventions provided by AAC experts tended to focus on improving activities and participation and were oriented toward improving functional communication.`The requested speech therapy is medically necessary for treatment of the patients medical condition. It is essential that the patient be provided with the resources necessary in order for him to communicate his wants and needs. Without the ability to use an AAC, he will be unable to express himself; including letting his family know when he is in pain. Therefore, the speech therapy is medically necessary.Final Result: The reviewer determined that the requested treatment 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 and neurology with special qualification in child 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 a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 49-year-old male enrollee requested surgical procedures related to anterior lumbar intercorporal fusion (ALIF) at L4-5 and dorsal fusion pedicle instrumentation at segment L3-5, irrespective of the implantation of total disc prostheses in segments L2-3 and L5-S1 for medical treatment of his low back pain and bilateral radicular pain or as a result of the two-segment artificial disc implantation. Findings:  The physician reviewer found that based on the available documentation, the ALIF at L4-5 and dorsal fusion pedicle instrumentation at segment L3-5, irrespective of the implantation of total disc prostheses in segments L2-3 and L5-S1 were not medically necessary for treatment of this patients low back pain and bilateral radicular pain or as a result of the two-segment artificial disc implantation. The efficacy of instrumentation and fusion as treatment for complex lumbosacral and pelvic regional pain syndrome remains controversial and the use of lumbosacral fusion is supported by Level III and Level IV case series studies at best. The accepted criteria for chronic pain with mechanical instability have not been demonstrated in the patients records. All told, the ALIF at L4-5 and dorsal fusion pedicle instrumentation at segment L3-5, irrespective of the implantation of total disc prostheses in segments L2-3 and L5-S1 was not medically necessary for treatment of this patients low back pain and bilateral radicular pain or as a result of the two-segment artificial disc implantation.
Appeal type: Medical Necessity
Decision: Upheld

A 53-year-old female enrollee requested authorization and coverage of a fully electric hospital bed for assistance with her Parkinsons disease. The Health Plan denied the request.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested equipment is not medically necessary at this time.
Appeal type: Medical Necessity
Decision: Upheld

A 59-year-old female enrollee has requested physical therapy for the treatment of her back pain.  Findings:  The physician reviewer found that The patient is suffering from chronic symptoms with intermittent flare-ups.  She has had no neurological deficits on physical examination.  Additionally, she has had minimal pain at rest, with pain occurring primarily with activities such as walking, running, hiking and weight training. The additional physical therapy modalities utilized have little proven benefit in the medical literature.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 58-year-old male who has requested authorization for a bariatric surgery consultation.  He is 61, weighs 329 pounds, and has a body mass index (BMI) of 43.4. In addition, he has significant comorbid conditions. The Health Plan has denied authorization and coverage for the consultation with a bariatric surgeon based upon their determination that it is not medically necessary for treatment of the patients medical condition.With a BMI of 43 and comorbid conditions, the patient meets nationally accepted medical necessity criteria for consideration of weight loss surgery. It is highly likely that bariatric surgery will be beneficial for this patient. The fact that there is no documentation of medically supervised weight loss should not preclude a consultation for bariatric surgery. There is no scientific evidence demonstrating that structured diet or exercise plans have been successful in the treatment of the morbidly obese. In fact, the Swedish obesity study identifies that even though there may be reduction or resolution of some symptoms with diet and exercise, surgery has the longest and best long-term outcome for the morbidly obese. The patient needs to be evaluated by a bariatric surgeon to determine whether he should proceed with weight loss surgery. A consultation with a bariatric surgeon is medically indicated and necessary for evaluation of this patients morbid obesity.Based upon the information set forth above, I have determined that the requested consultation is medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned. In addition, if upon consultation with a bariatric surgeon, weight loss surgery is recommended and the patient undergoes a formal psychological evaluation and is found to be an appropriate candidate for weight loss surgery, the surgery should be authorized.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for celiac plexus nerve block. A study concluded that the primary benefits celiac plexus blocks may be in reduced opiate dependence and opiate-associated side effects, which in turn improves quality of life. Celiac plexus block and neurolysis are safe and effective treatments for chronic upper abdominal pain and should be considered early in patients experiencing such symptoms. In this case, the patient has chronic abdominal pain related to multiple abdominal surgeries and has attempted non-interventional treatment in the form of cognitive behavioral therapy (CBT), a chronic pain management program, and physical therapy without substantial pain relief. She is currently taking Percocet for pain control with suboptimal results. The patients pain is severely impairing her quality of life with reports of poor sleep and the inability to sit for longer than 20 minutes. She reports having previous had celiac plexus blocks to manage her pain three to four times per year, with each injection providing several months of relief. In addition, the records indicate that the patient previously achieved adequate pain relief with celiac plexus blocks with good benefit and improvement in her quality of life. Based on the medical records available for review, the requested celiac plexus nerve block is medically necessary for 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 management 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 Harvoni for treatment of her hepatitis C virus. Findings:  The physician reviewer found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic Hepatitis C should be treated except those with limited life expectancy due to nonliver-related conditions. This applies regardless of fibrosis stage or viral load. Per guidelines, non-cirrhotic genotype 1 patients who have failed PEG-interferon and ribavirin should be treated with Harvoni for 12 weeks. These guideline recommendations are based on multiple randomized clinical trials, and the medication is U.S. Food and Drug Administration (FDA) approved for all patients with chronic hepatitis C, genotype 1 regardless of fibrosis stage. The recommendations are the same if the patient is considered treatment-naive.  AASLD/IDSA guidelines cite data showing decreased survival with delayed treatment. For these reasons, the requested treatment with Harvoni 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

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for viscosupplement/hyaluronic acid injections. The submitted documentation does not support the medical necessity of the requested medication. The evidence-based peer-reviewed literature supports the use of viscosupplementation injections for the treatment of pain in patients with severe osteoarthritis of the knee who have failed conservative treatment, including corticosteroid injections. Viscosupplementation has been found to be safe and effective and allow for delay of total knee replacement. In this case, the patient has been diagnosed with advanced osteoarthritis of the right knee. However, the patient recently completed physical therapy with improvement noted, and underwent a recent corticosteroid injection, with no documentation of inadequate response. Therefore, in this clinical setting, the requested viscosupplement/hyaluronic acid injections are not medically necessary for the treatment of the 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 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the cell-free fetal DNA prenatal testing (CPT code 81422) that was performed. The Health Plan has denied the service at issue as investigational for evaluation of the enrollees fetus.Findings:  Two out of three physician reviewers found that a cohort study of 8,141 pregnancies evaluated with noninvasive prenatal screening (NIPS) found that the accuracy of trisomy 21 detection was higher than that of other chromosome aneuploidies. Additionally, the positive predictive value for chromosomal deletions was low. It is therefore important to improve the specificity, accuracy and sensitivity of NIPS technology on the detection of subchromosomal microdeletions and microduplications. The patient is at high risk for a fetal aneuploidy based on her age. However, NIPS without microdeletion testing has been demonstrated to have a high degree of sensitivity and accuracy. The addition of cell-free fetal DNA prenatal testing at issue in this case was to evaluate for fetal chromosomal microdeletions, which is not supported by current medical literature. As such, the cell-free fetal DNA prenatal testing (CPT code 81422) that was performed on was not likely to be more beneficial for evaluation of the patients condition than any available standard therapy.Final Result: The reviewers determined that the requested test was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: Physician reviewers 1and 3 are board certified in medical genetics and genomics and are actively practicing. Physician reviewer 2 is board certified in clinical biochemical genetics 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for transforaminal epidural steroid injection. Epidural steroid injections can be beneficial for lumbar radicular pain. In this patients case, physical examination showed right lower extremity sensory deficits and positive straight leg raise test. With regards to epidural injections, the current medical evidence supports no more than three to four injections in one location of the body in a 12-month period. Additionally, the patient should experience at least 50% benefit for six to eight weeks in order for repeat injections to be medically necessary. The patient should not be on blood thinners. If the patient is on blood thinners, this medication should be held accordingly to the type of blood thinner the patient is on. Although the records do not document the patients pain relief following the most recent procedure, he had at least 50% benefit from his prior injections. The patient received the injections in 2018, and it has been greater than three months since his last injection. Therefore, transforaminal epidural steroid injection is medically necessary for the 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 sub-specialty certificaiton 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

A 64-year-old male enrollee has requested for stereotactic body radiotherapy (SBRT)  or in the alternative, external beam radiation therapy (EBRT) for treatment of the his pancreatic cancer.  Findings:  The physician reviewer found that stereotactic body radiotherapy (SBRT), delivering high fractional (8-20 Gy) doses in 1-5 fractions, with image guidance or other means to improve precision, is an established approach for the treatment of discrete lesions from cancer. In addition, there are several publications describing improved health outcomes in patients treated with SBRT for pancreatic cancer. In 2004, Koong and colleagues conducted a Phase I trial in which 15 patients with unresectable pancreatic cancer received single fraction SBRT, escalated from 15 to 25 Gy. No acute grade 3 toxicity was observed. In the authors subsequent Phase II study, 16 patients received 45 Gy with intensity modulated radiotherapy (IMRT) followed by a single 25 Gy SBRT fraction. Late toxicity occurred in some patients who developed grade 2 duodenal ulceration 4-6 months after SBRT. Chang and colleagues reported on 77 patients (45 locally advanced/inoperable, 11 medically inoperable, 15 with metastases, and 6 with local recurrence) who received SBRT (25 Gy x 1). It was noted that 16 patients had received prior EBRT. The 12-month local control was 84%. At 6-months and 12-months, the rates of grade 2 or greater late toxicity were 11% and 25%, respectively. The authors concluded that, SBRT for pancreatic adenocarcinoma was effective for local control with associated risk of toxicity and should be used with rigorous attention to quality assurance. Efforts to reduce complications are warranted. Overall, clinical studies have shown SBRT to be effective in the treatment of unresectable pancreatic cancer. Although there are no published studies that directly compare SBRT to conventionally fractionated radiation (either with IMRT or conventional radiotherapy), a recent American Society of Radiation Oncology (ASTRO) model coverage policy supports SBRT as medically necessary for locally advanced pancreatic cancer. This model policy reflects not only expert opinion, but is also evidence-based on the current peer reviewed medical literature. SBRT is only considered medically necessary for patients with good medical condition/performance status and for those whose tumor burden can be targeted, as in this patients case. Thus, SBRT has been demonstrated to be a medically necessary treatment of this patients locally advanced pancreatic cancer.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a two-year-old male has requested speech therapy (24 individual therapy visits and 12 group therapy visits) for treatment of his speech delay.  Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of a portion of the requested therapy.  As noted by Nelson and colleagues, speech and language development is considered by experts to be a useful indicator of a childs overall development and is related to school success.  Per the authors, identification of children at risk for developmental delay or related problems may lead to intervention services and family assistance at a young age when chances for improvement are best.  Speech and language delay must be taken seriously in young children, because the long-term consequences may be substantial.  As noted by Law and colleagues, approximately 6% of children have speech and language difficulties.  The authors noted that children whose difficulties persist into primary school may have long-term problems concerning socialization, literacy, behavior, and school attainment.  These reviewers concluded that there is a positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulties.  This patient demonstrates expressive and receptive language delay, and this is negatively impacting his ability to communicate his wants and his needs.  The current literature supports the use of speech and language therapy to address expressive deficits and facilitate the development of age-appropriate communication skills.  In this patients case, it is medically appropriate to receive speech therapy for a limited period of time to see if gains can be made in communication skills.  Specifically, 12 individual therapy visits, followed by a subjective evaluation to determine progress, are medically indicated for the treatment of this patient.  The submitted clinical notes fail to demonstrate the medical necessity of the requested 12 group therapy visits.  All told, a portion of the requested therapy is medically necessary in this clinical setting.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 37-year-old female with a body mass index (BMI) of 40. She is requesting authorization for a Lap-Band procedure. She has also reported a number of comorbid conditions including depression and obstructive sleep apnea. At issue is whether Lap-Band is medically necessary for treatment of the patients condition.Current scientific literature does not demonstrate that Lap-Band surgery results in any clear benefit for any specific group of patients. Most of the scientific data available have small numbers, short-term follow-up, and unacceptable success rates. Thus, gastric banding is less efficacious than alternative weight loss procedures and is not indicated in this case. The patient can be appropriately treated with standard laparoscopic bariatric surgery. Therefore, I have determined that the requested procedure is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 14-year-old female enrollee has requested continued physical therapy for treatment of the enrollees closed fracture of the left patella. Findings:  The physician reviewer found that the submitted documentation demonstrates the medical necessity of the requested services in this patients case.  The medical records indicate that the patient continues to have significant knee stiffness and pain, as well as difficulty climbing stairs.  Based upon the documentation, the patient requires the use of a knee brace.  The current medical evidence supports continued physical therapy in this clinical setting.  This patient continues to have functional impairment, and her condition requires treatment by a skilled physical therapist.  All told, continued physical therapy is medically indicated for the treatment of this patient.