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

Nature of Statutory Criteria/Case Summary:  An enrollee has requested reimbursement and prospective authorization and coverage for submucosal radiofrequency ablation of the tongue base. Findings: Two out of three physician reviewers found that submucosal radiofrequency ablation of the tongue base was and is likely to be more beneficial for you than any available standard therapy.Radiofrequency tongue base reduction has been found to be beneficial for the treatment of obstructive sleep apnea for patients with primarily tongue base abnormalities, especially in patients with a low body mass index (BMI). The standard of care for the treatment of OSA is continuous positive airway pressure (CPAP). In this case, the patient has a history of severe OSA with an apnea-hypopnea index (AHI) of 36.7. The patients BMI is low at 19.5. Records indicate that the patients primary issue on examination was a tongue base problem. The patient has been using a CPAP for several years but has been having difficulty tolerating it partly due to cumbersome equipment and claustrophobia. There is sufficient support for the services at issue in this clinical setting. Therefore, submucosal radiofrequency ablation of the tongue base was and is likely to be more beneficial than any other available standard treatments for the patients medical condition.Final Result: The reviewers determined that the services at issue were and are likely to be more beneficial than any available standard treatment for the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer 1 is board certified in internal medicine with sub-specialty certification in sleep medicine. The reviewer 2 and reviewer 3 are board certified in otolaryngology. All reviewers are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 32-year-old female has requested the medication Provigil for treatment of idiopathic hypersomnolence.  Findings:  The physician reviewer found that there is insufficient evidence that the patient has idiopathic hypersomnia. A study by Richardson, et. al. reported that normal individuals usually demonstrate a mean sleep latency of greater than 10 minutes and pathologic daytime sleepiness is defined as a mean sleep latency of less than five minutes. The findings do not support a diagnosis of idiopathic hypersomnia.
Appeal type: Medical Necessity
Decision: Upheld

The patient has requested reimbursement for skilled nursing facility (SNF) services. The records provided for review do not support that this patient required treatment at the SNF level of care. The patient did not require skilled nursing services with the specialized skill, knowledge, and judgment of a skilled professional nurse. The patient did not have a tracheostomy tube, enteral feedings, complex wound care, or other SNF level of care nursing need. This patients functional level and weight bearing limitations did not require ongoing SNF level skilled therapy services. The patient did not require these skilled nursing or skilled therapy services on a daily basis. Although the patient might have benefited from physical and occupational therapies, these services were not required on a daily basis in the SNF setting. All told, the SNF services 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 physical medicine and rehabilitation with subspecialty certification in neuromuscular 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

The parent of a two-year-old male enrollee has requested a battery operated nebulizer  for treatment of the enrollees asthma. Findings:  The physician reviewer found that that asthma is an inflammatory process characterized by airway obstruction due to airway hyper-responsiveness, bronchospasm, airway inflammation, and mucus production. Gas exchange abnormalities are due to ventilation/perfusion mismatch, as a result of atelectasis and airway over-distention. Status asthmaticus is defined as severe asthma that fails to respond to inhaled beta-agonists, oral or intravenous steroids, and requires admission to the hospital for treatment (Helfaer, et al). Fu and Tsai noted that acute exacerbations continue to be a major problem in patients. The authors reported that early episodic intervention appeared to be crucial in preventing severe attacks and future exacerbations. Inpatient admission is indicated for patients with mild to moderate status asthmaticus, and intensive care unit (ICU) admission is necessary for patients with history of ICU admissions or rapid deterioration, severe distress with air hunger despite bronchodilator therapy, respiratory arrest, or rising CO2 with clinical signs of fatigue. Critically ill children require fluid resuscitation, aggressive bronchodilator therapy, corticosteroids, and occasionally mechanical ventilation. In an effort to control this patients asthma, the requested battery operated nebulizer is supported as medically necessary for treatment of his medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/ Case Summary:  The enrollee requested authorization and coverage for the medication, Otezla. According to the record, the enrollee has severe plaque psoriasis and hypertension. He has painful lesions with silvery scales on his trunk, upper and lower extremities, and genitals, which constitute 80% of his body surface area. Treatment with Triamcinolone, Fluconazole, Ciclopirox, Ketoconazole, Vanicream, and Prednisone has been unsuccessful. His physician indicates that he is not a candidate for light therapy due to his travel schedule and time restraints. The physician expressed concern regarding systemic therapies due to black-box warnings for methotrexate regarding liver damage, and for interactions between methotrexate and Lisinopril, the enrollees hypertension medication as interactions can worsen liver-damaging side effects. The physician indicated similar black-box and medication interaction concerns with the systemic use of cyclosporine for this enrollee. The enrollees dermatologist began a trial of Otezla (apremilast) following which skin lesions had improved enough to allow him to maintain his activities of daily life without pain. His dermatologist is recommending Otezla for relief of disease symptoms without the risk of side effects. Review of the record indicates the enrollee is on atorvastatin, which contraindicates the use of methotrexate and acitretin.  Cyclosporine is contraindicated since he has hypertension. Notes indicate compliance with phototherapy would be difficult due to the enrollees work/travel schedule. Per the medical literature, apremilast (Otezla) was approved for use in treating moderate-to-severe plaque psoriasis. A clinical study demonstrated that 29 percent of patients receiving 20mg of apremilast twice a day and 41 percent of patients receiving 30mg of apremilast twice a day achieved a 75-percent reduction in symptoms by week 16. Study participants receiving a placebo achieved a 6-percent reduction in symptoms. Apremilast also demonstrates efficacy for treating plaque psoriasis involving the male genitalia. The mode of action appears to diminish cellular inflammation and keratinocyte activation/proliferation. 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 dermatology 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

Nature of Statutory Criteria/Case Summary:   An enrollee has requested reduction mammaplasty, panniculectomy, and abdominoplasty for treatment of her medical condition.  Findings:  The physician reviewer found that the request for reduction mammaplasty and panniculectomy are medically necessary for treatment of the patients medical condition. The patient presents with well-documented signs and symptoms of significant symptomatic macromastia and a symptomatic lower abdominal pannus that has failed reasonable conservative dermatologic management.  Her photographs, multiple examinations and recommendations from multiple physicians have supported her condition and she would likely have functional improvement from surgical intervention in the form of bilateral breast reduction and lower panniculectomy. Reduction mammaplasty is a well-known procedure that directly addresses functional deficits and is appropriate given the above factors.  In addition, the patient has symptomatic lower abdominal pannus that has failed reasonable non operative treatment. Her functional deficits would likely be significantly improved with lower panniculectomy. Thus, panniculectomy is medically necessary for treatment of the patients medical condition. However, the request for abdominoplasty has not been established as medically necessary for treatment of the patients medical condition. There is insufficient medical documentation that a functional deficit exists for the upper abdomen that would be corrected with an abdominoplasty. Thus an abdominoplasty, which treats the upper abdomen, is not medically indicated. The functional impairment of this patient is likely related to the lower abdomen and not the upper abdomen. According to the American Society of Plastic Surgeons a panniculectomy to eliminate a large hanging abdominal panniculus and its associated symptoms would be considered reconstructive. Abdominoplasty typically performed for cosmetic purposes, involves the removal of excess skin and fat from the pubis to the umbilicus or above, and may include fascial plication of the rectus muscle diastasis and a neoumbilicoplasty. Thus, the abdominoplasty is not medically necessary.  Final Result: The reviewer determined that a portion of the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned.  Credentials/Qualifications: The reviewer is board certified in plastic 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 57-year-old male enrollee has requested Tarceva for the treatment of his pancreatic cancer. Findings:  Three physician reviewers found that Tarceva has been found to be of marginal effectiveness in combination with Gemzar in the initial treatment of pancreatic cancer. There is no data whatsoever as to its efficacy in combination with any other chemotherapy drugs or as a second or third-line therapy for pancreatic cancer. The use of Tarceva is certainly investigational and is of no known clinical benefit.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a two-year-old female enrollee has requested speech therapy for treatment of the enrollees delays in receptive and expressive language skills and social/pragmatic language skills. Findings:  The physician reviewer found that approximately 5% of preschool children will exhibit speech and language delay. There is evidence that preschool children with developmental speech and language disorders are at increased risk for difficulty with reading when they enter school.  There is evidence that early intervention can improve speech and language skills over short-term follow-up.  Recent studies have reported an overall positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulties.  In this patients case, given the degree of speech and language delay, speech therapy is standard of care. There is adequate support in the medical literature for the efficacy of the requested services in this clinical situation.  All told, in this patients case, the requested speech therapy is medically indicated.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for digital breast tomosynthesis for the enrollees breast cancer screening. Findings:  Three physician reviewers found that the patient has a history of having had a right sided stereotactic biopsy of her right breast and then an excisional biopsy of her right breast.  In addition, she has had prior augmentation mammoplasty. However, the implants were removed. She underwent a routine screening mammogram consisting of a combination two dimensional and three dimensional tomosynthesis examination.  The current images were compared to prior mammograms and no interval changes were noted. There were no masses, areas of suspicious calcifications, or areas of architectural distortion.  Her breasts were described as heterogeneously dense. The Health Plan has denied reimbursement for digital breast tomosynthesis performed.  Per the Health Plan, the service at issue was investigational for the evaluation of this patient. Breast tomosynthesis is a technique that was developed several years ago as a problem solving adjunct to routine mammography.  Applying the same basic concept as computed tomography scanning, the logic is that by separating the various layers of breast tissue, one can better detect abnormalities. This has been shown to be most useful in the evaluation of dense breasts. In this particular patient, she has breast tissue that was described as being heterogeneously dense.  While one could make the argument that her mammogram has not changed since the last study, it is specifically those patients who have dense breasts that can benefit most from tomosynthesis.  The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor. In sum, digital breast tomosynthesis performed was likely to have been of greater benefit than other methods of evaluating this patient. Final Result: The reviewers determined that the service at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: All three reviewers are board certified in diagnostic radiology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 23-year-old female enrollee has requested psychiatric residential treatment services for treatment of her behavioral health problems. Findings:  The physician reviewer found that the submitted clinical documentation is not adequate to support the contention that the patient warranted residential treatment. It is clear that by the point of admission the patient was rather variable in the extent of her binging and purging, was quite motivated for treatment, and was both tolerating previously prescribed Lexapro as well as devoid of depression. Therefore, there does not appear to have been a medical indication for intensive treatment services along the lines of residential care. The patient was likely to benefit just as much from a less intense level of treatment.
Appeal type: Experimental/Investigational
Decision: Upheld

A 51-year-old male enrollee has requested Avastin for the treatment of his radiation necrosis. Findings:  Three physician reviewers found that Avastin is FDA approved for lung and colon cancer. It has shown intriguing early activity in high grade glioma of the brain. The role of Avastin in low grade brain tumors (ependymoma) has not been well studied. Additionally, Avastin has not been adequately studied in the setting of radiation necrosis. In a small pilot trial of 15 patients, there appeared to be radiological improvement in 8 patients. However, the improvement in patient symptoms, quality of life and the side effects in this setting have not been well characterized. We do not know from this small pilot study if there is sufficient clinical benefit to justify the risks of Avastin.
Appeal type: Medical Necessity
Decision: Upheld

A 51-year-old female enrollee requested authorization and coverage of BRCA testing for genetic screening for breast cancer.  The health plan denied the enrollees request indicating that the requested testing is not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer upheld the health plans denial on the basis that the requested testing is not medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for autologous hematopoietic stem cell transplantation for treatment of the enrollees multiple sclerosis. Findings:  The 3 physician reviewers found that the submitted documentation fails to demonstrate the superior efficacy of the requested services. The medical records provided for review do not indicate that the patient has failed or is otherwise unable to tolerate or take other U.S. Food and Drug Administration (FDA) approved treatments for multiple sclerosis. The records note treatment with Betaseron and Copaxone. However, multiple other therapies are available and FDA approved with demonstrated efficacy and low morbidity for multiple sclerosis. The medical evidence has not demonstrated that the efficacy of autologous hematopoietic stem cell transplantation exceeds other available multiple sclerosis therapies. Thus, the requested autologous hematopoietic stem cell transplantation is not likely to be more effective than other treatment options. Final Result: The 3 reviewers determined that the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewer number one 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 a similar medical condition.Physician reviewer number two 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 a similar medical condition.Physician reviewer number three 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 a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 53-year-old male enrollee has requested right ear keloid excision for treatment of his mass on his right ear lobe.   Findings:  The physician reviewer found that review of the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested procedure. The patient has an enlarging, painful keloid that developed behind the right ear. Keloids tend to grow but not to spontaneously regress, and can be associated with pain. As keloids often recur following excision, which produces further trauma to the skin, surgical excision is not considered first-line therapy. Keloids can be effectively treated or reduced in size to lessen pain, with intralesional steroid injections, cryotherapy or injectable 5-fluorouracil, in combination with external pressure application (Weshahy and Abdel; Love and Kundu). As there is no evidence that other conservative measures have been attempted, the request for coverage of excision is not medically necessary. The patient should pursue other treatment options first, as larger keloids can result after surgical excision. For the reasons set forth above, the requested procedure is not medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 35-year-old female enrollee has requested for transcranial magnetic stimulation (TMS) therapy for treatment of the enrollees mental health condition. Findings:  Two physician reviewers found that The FDA has approved TMS as a specific treatment for severe depression and has provided guidelines for its use. Additionally, the American Psychiatric Association (APA) included TMS in their 2010 guidelines as an appropriate acute phase treatment option for patients who do not respond adequately to medication therapy. Further, the American Medical Association (AMA) has approved Category I CPT codes for TMS effective in January 2011. Several articles are cited from the literature that shows that TMS compares favorably with ECT. Grunhaus and colleagues reported that their conclusion is particularly relevant because it suggests that rTMS and ECT reach similar results in nonpsychotic major depressive disorder. Similarly, Eranti and colleagues noted that although ECT was more effective in the short term, at 6 months the HAM-D scores did not differ between groups. Self- and observer-rated cognitive measures were similar in the two groups.  Although this patient has suffered significant side effects from multiple different treatments, her diagnosis is not clear at this time, as there are different diagnoses being reported by the patient and the patients provider. At the present time, this patient does not meet the FDA criteria for TMS treatment, in that she is not presenting with a definite diagnosis of major depressive disorder (MDD).  While bipolar disorder, depressed type and MDD share common features, they are not the same disease. Therefore, based upon the documentation provided, treatment with TMS is not likely to be more beneficial for treatment of this patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld

The parent of an 11-year-old female enrollee has requested modafinil 100 mg tablet (Provigil) for treatment of the enrollees daytime sleepiness. Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the requested medication. There is a lack of medical literature demonstrating that Provigil is safe and effective for pediatric patients. In addition, per the U.S. Food and Drug Administration (FDA) approved medication guidelines for Provigil, It is not known if Provigil is safe or if it works in children under the age of 17. Based on the medical literature cited above and the documentation submitted for review, the request for modafinil 100 mg tablet (Provigil) is not medically necessary for treatment of the patients medical condition.