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

The parent of a 17-year-old female enrollee has requested for the prescription medication Provigil for treatment of the enrollees attention deficit disorder (ADD). Findings:  The physician reviewer found that a review of the literature supports the premise that behavioral interventions and/or other stimulant or non-stimulant medications may be more beneficial for this patient than Provigil. Provigil is indicated for the treatment of adults with excessive daytime sleepiness, fatigue related to multiple sclerosis, obstructive sleep apnea and shift/work disorder. It is not indicated for the treatment of ADD in the child or adult population.
Appeal type: Medical Necessity
Decision: Upheld

A 49-year-old male enrollee has requested a power wheelchair for treatment of the enrollees medical condition.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested equipment.  The records indicate that the patient has normal strength in the upper limbs and poor to trace strength in the lower limbs.  There are no indications that he does not have functional active range of motion in the upper limbs.  Additionally, there are no indications that he has cardiopulmonary or other organ system impairments that would preclude propulsion of a manual wheelchair within the home to perform daily activities.  The records forwarded for review do not establish that the patient would be bed or chair confined without a power mobility device.  This patient has multiple chronic health conditions, such as chronic obstructive pulmonary disease and hypertension, which would benefit from increased physical activity and exercise.  Regular use of a power mobility device would decrease his physical activity levels and would be expected to worsen his health conditions.  Manual wheelchair use has been shown to provide significant health benefits over power wheelchair use for persons with mobility impairments.  All told, the requested power wheelchair is not medically indicated in this patients case.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Xyrem 500 mg/mL solution, 4.5 grams, two times per day. Xyrem is a central nervous system depressant that has been approved by the U.S. Food and Drug Administration (FDA) the treatment of narcolepsy. Narcolepsy is a common cause of daytime sleepiness. It is a syndrome of daytime sleepiness with cataplexy, hypnagogic hallucinations and sleep paralysis. In order for a diagnosis of narcolepsy to be made, both a polysomnogram and multiple sleep latency test (MSLT) should be performed. The diagnosis of narcolepsy is confirmed with a polysomnogram that rules out other sleep disorders and a MSLT that demonstrates an average sleep latency less than eight minutes and/or at least two sleep onset rapid eye movement periods. In this case, the documentation submitted for review does not show that the patient has had a detailed sleep assessment or confirmatory testing. It appears that the requested medication has been used for a diagnosis of chronic fatigue syndrome, and this is not an FDA approved indication. Therefore, for Xyrem 500 mg/mL solution, 4.5 grams, two times per day 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 and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The patient has requested authorization and coverage for Alphagan P eye drops. The authors concluded that there was no statistically significant difference in the intraocular pressure (IOP)-lowering efficacy of the medications evaluated. This patient has been treated with timolol, with increased IOP levels, for her diagnosis of primary open angle glaucoma. Treatment with Alphagan P resulted in improved IOP levels. However, there is a lack of data demonstrating that higher concentrations of brimonidine would not be as effective and might cause side effects not observed with Alphagan P. The records provided for review do not demonstrate that the patient has failed treatment with the Health Plans formulary alternatives, which include a generic formulation of brimonidine. Thus, the requested Alphagan P eye drops are not medically necessary for 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 ophthalmology 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 40-year-old male enrollee requested weekly psychotherapy visits for medical treatment of his behavioral health condition.  Findings:  The physician  reviewer  found that the patients therapist reported that the patient had achieved remission, which is indicative of clinical progress and the consolidation of treatment gains. Thus, a reduction in the services needed to achieve remission would be safe and appropriate.  There is no evidence that less-frequent therapy would hasten a clinical deterioration and necessitate treatment at a higher level of care. In sum, based upon the documentation provided, there is a lack of support demonstrating the medical necessity for psychotherapy visits at a frequency of once per week. Thus, the services are not medically necessary for treatment of the patients behavioral health condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Synvisc injection for the left knee. Per the medical literature, although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. The current evidence is limited, and guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate that the evidence is not conclusive. In light of the foregoing, viscosupplementation can only be recommended in individuals with a history of lasting benefit from prior injections, and in carefully selected cases where everything else has been tried, and the options are limited. In this case, the patient has a history of chronic left knee pain due to osteoarthritis. He has tried and failed other conservative measures, and the degree of osteoarthritis is not severe enough for a total knee arthroplasty. Given the patients limited options and based on the current medical literature, the requested service is medically indicated. Therefore, Synvisc injection  for the left knee 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 orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 58-year-old man with a long-standing history of gout with painful attacks in the elbow.  It has been recommended the patient undergo a bursectomy and excision of the gouty tophi. The Heath Plan has denied authorization and coverage for the requested surgery on the basis it is not medically necessary for treatment of the patients elbow pain.The patient has painful masses within the olecranon bursa that require surgical intervention. The requested surgery has been recommended in order to resolve a functional impairment. Without surgical intervention, it is not likely the patients pain will resolve. The requested surgery is medically appropriate and indicated in order to relieve the patients pain. Therefore, I have determined the requested surgery is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Upheld

The enrollee requested reimbursement for Hyalomatrix dressing for a buttock wound developed after radiation treatment for metastatic rectal cancer. Wound care consists of silver alginate dressing, changed four to five times per day due to drainage. The enrollee was referred for hyperbaric oxygen chamber wound treatment. The provider also requested Hyalomatrix to assist with wound healing. At a wound clinic visit the enrollee indicated the wound had not changed in size or drainage pattern. He reported the excessive wound drainage negatively impacts his life. The physician assistant indicates the enrollee would like to avoid surgery and his wound has improved with the use of the Hyalomatrix dressing. Review of the medical literature indicates there is no scientific, evidence-based support for a significant benefit associated with the application of the Hyalomatrix dressing for this enrollees clinical condition. Studies that support the effectiveness of Hyalomatrix dressing use on wounds are anecdotal, which is the weakest level of evidence, and have not been shown to be more beneficial than other standard therapies. Most studies regarding Hyalomatrix are related to burn patients, and they do not address the complexity related to buttock wounds. Unlike hyalomatrix dressing, other treatment modalities, such as vacuum seal, have studies that looked specifically at its use on the buttock and the perianal areas, and the contribution of bacterial load to infection and the healing rate/process. To date, studies on hyalomatrix dressing are not specific to this patient's case; which is a buttock wound secondary to radiation therapy for his rectal cancer. Thus, this treatment modality is not clinically comparable to other treatment modalities for his buttock wound.   There are no studies in the medical literature to support the safety and efficacy of the requested Hyalomatrix dressing in this clinical setting. Final Result: Three of three medical experts decided that the requested treatment was not likely to have been more beneficial than any other available standard treatment for the enrollees medical condition.Credentials/Qualifications: Three reviewers are board certified in Vascular Surgery 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Privigen (intravenous immune globulin (IVIG) for treatment of the enrollees chronic inflammatory demyelinating polyneuropathy (CIDP). Findings:  The physician reviewer found that although IVIG is standard treatment of CIDP, the documentation submitted for review does not support the diagnosis in this case. In general, the following criteria support the diagnosis of CIDP: progression over at least two months, weakness more than sensory symptoms, symmetric involvement of arms and legs, proximal muscles involved along with distal muscles, reduced deep tendon reflexes throughout, increased cerebrospinal fluid protein without pleocytosis, nerve conduction evidence of a demyelinating neuropathy and nerve biopsy evidence of segmental demyelination with or without inflammation. The primary goal of therapy in patients with the Guillain-Barre syndrome (GBS) and chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) is improved strength and functional ability. Improvement in pain, sensory loss, gait disorder, and autonomic instability are other goals of therapy. Patients with very mild symptoms that do not interfere with activities of daily living can be observed for deterioration without treatment. In this case, the documentation submitted for review does not provide the patients degree of pain and disability. In addition, an EMG in isolation and a history of stable symptoms for 20 years do not support a diagnosis of CIDP. Even with a diagnosis of CIDP, the use of IVIG is based on clinical symptoms. Given the lack of clinical data to support a diagnosis of CIDP, the request for IVIG is not medically necessary. All told, the request for Privigen IVIG has not been established as medically necessary for treatment of the patients medical condition. 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 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 28-year-old female enrollee has requested Humira injections for the treatment of her ulcerative colitis. Findings:  The physician reviewer found that there is only one open-label trial of 10 patients who received Humira for ulcerative colitis; 4 were reported to have received a benefit, but the extent of that benefit was unclear.  There is no consensus about the role of Humira in the treatment of ulcerative colitis.  It does not have a role in therapy as yet defined.  The treatment proposed here is akin to a clinical trial, rather than an innovative practice.  The benefit of such treatment as an experimental approach for this patient is entirely unclear.
Appeal type: Medical Necessity
Decision: Upheld

Findings:  The physician reviewer found that The patient has requested authorization and coverage for (1) acupuncture services, and (2) acupuncture services (including scalp acupuncture, Jing Zheng, traditional Chinese medicine and Chinese herb therapy). In a systematic review and meta-analysis, Tu and colleagues concluded, Acupuncture was effective and safe in the patients with flaccid hemiplegia after stroke. Yu and colleagues reported, From the available evidence, acupuncture may have beneficial effects on improving dependency, global neurological deficiency, and some specific neurological impairments for people with stroke. Hu and colleagues report, Scalp acupuncture therapy combined with exercise therapy can significantly improve the ability of stroke patients to participate in daily activities. In this case, in an application for independent medical review, the patient reported having undergone acupuncture treatment that was helpful. While the provider noted excellent progression, the acupuncture services overlapped with other therapies. Despite being requested, the submitted records did not document pre-acupuncture and post-acupuncture baselines in activities of daily living-function for comparison purposes. The records did not include progress notes by the acupuncturist documenting any measurable, progressive, significant, objective functional improvement or quantifiable responses to treatment obtained with the acupuncture sessions already completed. Physical therapy progress notes reported that the patient progressed with the rehabilitation instituted. In this clinical setting, given the lack of documentation of specific benefits directly attributed to the use of acupuncture, scalp acupuncture, and other techniques used by the acupuncture provider, the requested services are not medically indicated. Therefore, (1) acupuncture services, and (2) acupuncture services (including scalp acupuncture, Jing Zheng, traditional Chinese medicine and Chinese herb therapy) are not medically necessary for the treatment of this patient.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.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Otezla 30 mg for treatment of his rhematoid arthritis. Findings:  The physician reviewer found that Otezla is indicated for the treatment of psoriasis and psoriatic arthritis. However, there is a paucity of peer-reviewed evidenced based literature to support the use of Otezla in the treatment of rheumatoid arthritis. Given the absence of current scientific data supporting an indication for Otezla in treating patients with rheumatoid arthritis, Otezla 30 mg tablet is not indicated as medically necessary in 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 sub-specialty certification in rheumatology 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

An 18-year-old female enrollee has requested psychiatric residential treatment center (RTC) services for treatment of her depressive disorder.  Findings:  The physician reviewer found that the patient did not have any substance abuse, homicidal or suicidal thoughts or any psychosis. She had no co-occurring medical issues, she was not treated with psychotropic medications, and she did not require any medical treatment. Further, there is no evidence that outpatient therapy, medications, or other lower levels of care were utilized in the six months prior to this admission. Based on the patients records, she could have been safely and adequately addressed at a lower level of care on an outpatient basis. Therefore, the RTC level of care services provided from the said timeframe were not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 60-year-old female enrollee has requested Hyalgan (hyaluronic acid) injections for treatment of her osteoarthritis. Findings: The physician reviewer found that review of this patients medical records does not describe a case specific factor which would support the likelihood of a clinical benefit with the requested Hyalgan injections. In addition, the medical literature does not support the efficacy of repeated series of Hyalgan injections. To the contrary, the studies document level II evidence that hyaluronan injections have little to no efficacy in this setting. Well designed double-blinded placebo-controlled studies have not demonstrated a significant positive effect from intra-articular hyaluronan as compared to placebo. In the study conducted by Jorgensen and colleagues, no appreciable improvement was found in patients at 3, 6, 9, and 12 months after injection. In one study it was noted that 80 knees treated with hyaluronic acid and concluded that the therapy should probably be limited to patients with significant surgical risk factors or early osteoarthritic changes failing conservative treatment rather than patients with advanced degenerative osteoarthritis, as is documented in this case (Evanich and colleagues). It should be noted that repeat injections have potential complications including aseptic and septic arthrosis. Overall, there is insufficient evidence in the scientific studies to suggest that further hyaluronan injections are likely to be efficacious for management of this patients osteoarthritis of the knee. As such, it is not medically necessary for this patient to receive an additional Hyalgan injection.
Appeal type: Medical Necessity
Decision: Upheld

A 52-year-old male enrollee has requested nasal repair surgery and related surgical procedures for the treatment of his obstructive sleep apnea and septal deviation. Findings:  The physician reviewer found that the records provided do not document that the requested surgical procedures are medically indicated or necessary. There is no documentation of an anatomically significant septal deviation and there is no documentation of any trials of medical allergy treatment for the patients congestion. The Health Plan has authorized UPPP and tonsillectomy for this patient. There is no evidence that he is likely to obtain added benefit from the other proposed procedures. Even with multilevel surgery, he may continue to have sleep apnea, daytime sleepiness and hypertension. All told, the patients clinical findings do not support the necessity of the surgical procedures in dispute.
Appeal type: Medical Necessity
Decision: Upheld

A 50-year-old female enrollee has requested a reduction mammoplasty for treatment of her status post breast augmentation.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested procedure in this patients case.  The reviewed records support the existence of an extracapsular ruptured silicone implant on the right and capsular contracture on the left.  The records do not support the existence of macromastia or any macromastia related symptoms given the absence of shoulder bra strap grooving in the photographs.  The requested mammoplasty is not likely to relieve the patients symptoms.  The patients breasts will not constitute an abnormal structure of the body following breast implant removal and capsulectomy.  All told, the requested reduction mammoplasty is not reconstructive in nature and is not medically necessary for the treatment of this patient.