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

The patient is a 69-year-old male with a long standing disorder of sleep maintenance. He has had minimal response to Ambien 5mg and 10mg, and finds Lunesta 3mg significantly more effective than Lunesta 2mg. The patient reports improved sleep maintenance and subsequent improvement in daytime somnolence with the higher dosage of Lunesta. The patients request for authorization of Lunesta 3mg was denied by the Health Plan citing a lack of medical necessity.This patient has tried and failed various hypnotic agents. He had a long trial of Lunesta 3mg and found it to be the most helpful drug he has used. Neither the patient nor his provider have reported any adverse events with the higher dosage. The manufacturer may have made a general recommendation that the 2mg dosage be prescribed for patients over age 65, but that dosage has been found to be inadequate for this particular patient. Despite the package insert information, the treating physician may use a higher dosage at his/her discretion if he considers it medically indicated. Therefore, I have determined the requested medication is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for a standing frame device provided.Findings:  The physician reviewer found that the current medical evidence supports the device at issue in this clinical setting. This patient has impaired mobility due to a cervical spinal cord injury.  A study noted sitting for more than eight hours per day has been shown to increase mortality while standing is a healthier alternative that can positively affect mortality in adults. Researchers found that standing has a positive impact on range of motion, activities of daily living, bladder function, and skin. The literature shows that a standing frame has positive effects on the health of those with spinal cord injury. All told, the standing frame device provided was likely to have been more efficacious than other treatment options. Final Result: The reviewers determined that the device at issue was 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: Physician reviewers are board certified in physical medicine and rehabilitation and are actively practicing. The reviewers are 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 31-year-old female enrollee has requested for Endometrin for treatment of her history of preterm labor. Findings:  The physician reviewer found that the evidence does not demonstrate that this patient had a prior preterm birth. In addition, the regimen recommended for prevention of preterm delivery is, when possible, to initiate therapy between 16 and 20 weeks, continuing it until 37 weeks.  There is as yet no data to support the use of progesterone for patients who previously experienced preterm uterine contractions but no preterm delivery, except perhaps in patients who have a documented short cervix early in the pregnancy.  This patient did not have a documented short cervix.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a three-year-old male enrollee has requested a powered intracapsular tonsillectomy and adenoidectomy for the treatment of the enrollees marked adenotonsillar hypertrophy and obstructive sleep apnea. Findings:  The physician reviewer found that this patient has symptoms of obstructive sleep apnea syndrome. His symptoms include adenotonsillar hypertrophy, loud mouth breathing, heavy snoring and frequent pauses in the sleep at night. Surgical intervention can dramatically improve these symptoms. Evidence-based medical literature documents improvement of symptoms of obstructive sleep apnea in pediatric patients who have documented adenotonsillar hypertrophy and undergo surgical removal of the tonsils and adenoids for improvement of the airway.  However, appropriate services can be provided through the in-network designated specialty physicians. Although the methods may very slightly in the degree of postoperative pain and postoperative recovery, the specific method of performing the surgery does not appear to have any relevant improvement of the outcome.
Appeal type: Medical Necessity
Decision: Upheld

A 58-year-old male enrollee requested authorization and coverage of acute rehabilitation services for the treatment of diabetic neuropathy and fear of falling.  The Health Plan denied the enrollees request indicating that the requested treatment 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 services are not medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

The parent of a 13-year-old female enrollee has requested a colon motility (manometric) study for evaluation of the enrollees medical condition. Findings:  Three physician reviewers found the requested services are likely to be more efficacious than other modalities for evaluating this patient.  The current medical evidence supports the requested colon motility (manometric) study in this case.  A recent American Neurogastroenterology and Motility Society consensus statement has recommended this test for the assessment of severely constipated patients who are unresponsive to medical therapy, and who have evidence of slow colonic transit in the absence of an evacuatory disorder.  Colonic manometry has been proposed to discriminate normal colonic motility from colonic neuromuscular disorders in children.  Colonic manometry may help to assess function of a diverted colon prior to possible reanastomosis.  Therefore, the requested colon motility (manometric) study is likely to be of greater benefit than other methods of evaluation.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a seven-year-old female enrollee has requested speech and language therapy (once per week for six months) for treatment of the enrollees expressive language disorder.  Findings:  The physician reviewer found that this patients expressive language dysfunction stems from two etiologies. The first is that of brain maturation and organization.  Congenitally, the child has not developed language skills based on her cerebral development. Additionally, the speech pathologists evaluation indicated oral-pharyngeal motor difficulties, which again stem from a congenital dysfunction. Cognitively, the patients receptive skills are normal, which implies a normal intellect. Law and colleagues conducted a meta-analysis of the outcomes of speech therapy in intellectually normal children.  For the most part, such speech interventions are highly successful in developing expressive language in these children. Goorhius-Brouwer and colleagues also noted the success of developing expressive language in intellectually normal children.  There is adequate support in the medical literature demonstrating the efficacy of speech and language therapy in this clinical scenario.  All told, the requested speech and language therapy (once per week for six months) is medically indicated for this patient.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Medtronic G670 closed loop insulin pump system.  Findings:  The physician reviewer found that the Medtronic G670 System is approved is approved by the U.S. Food and Drug Administration (FDA) for continuous delivery of basal insulin and administration of insulin boluses for the management of type 1 diabetes. The Medtronic G670 system includes SmartGuard technology, which can be programmed to automatically adjust delivery of basal insulin based on continuous glucose monitor (CGM) sensor glucose values, and can suspend delivery of insulin when the sensor glucose value falls below or is predicted to fall below predefined threshold values. Studies show that the Medtronic G670 system increased the percent of in-target [sensor glucose] SG levels and was associated with clinically important reductions in HbA1c values in both cohorts. These findings and the ability of the system to increase the time in-target range, while reducing the time below and above target levels, support its function as a hyperglycemia and hypoglycemia attenuator . Studies also show that the closed-loop insulin delivery at home reduces mean glucose and increases time in target without increasing the risk of hypoglycemia in adults with relatively well-controlled type 1 diabetes . A peer reviewed study  showed that among adults, the glycated hemoglobin level was lower with the use of a closed-loop system day and night than with a sensor-augmented insulin pump, even when the insulin pump was adjusted appropriately. In this case, the patient has type 1 diabetes that is sub-optimally controlled. The patients HbA1c is above 6.5%. The Medtronic G670 system automatically make corrections when the patient is trending to hypo- or hyper-glycemic range. Thus, this system will allow the patient to remain within the recommended target range and maintain the patients HbA1c while minimizing hypoglycemic and hyperglycemic events. As such, the Medtronic G670 system is likely to be more beneficial for treatment of the patients type 1 diabetes than any available standard therapy.Final Result: All three reviewers determined that the requested device is 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: Physician reviewers are board certified in internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested intensity modulated radiation therapy (IMRT) for treatment of her medical condition. Findings:  Three physician reviewers found that there is literature to support the benefit of IMRT in the treatment of gastric cancer.  The study by Ringash and colleagues showed improved target coverage with IMRT versus conventional 3D conformal radiation. In addition, IMRT reduces the dose to the liver and kidneys (Milano, et al; Minn, et al) as well as the heart and spinal cord. In a study by Minn and colleagues, 57 patients treated with IMRT for gastric cancer resulted in improved kidney and liver, and a significantly lower risk of renal toxicity after radiation. In this case, the medical records justify IMRT for this patient to reduce normal tissue dose exposure. As such, the services at issue were likely to be more beneficial for treatment of the patients medical condition than any standard treatments. Final Result: Three reviewers determined that the services at issue were 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:  All three reviewers are board certified in radiation oncology 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the peripheral nerve block for treatment of the enrollees left heel pain. Findings:  The physician reviewers found that in the peer-reviewed medical literature, there is a paucity of support for a posterior tibial nerve block prior to a cortisone injection for treatment of plantar fasciitis. The patient was being treated for a diagnosis of plantar fasciitis, with an injection of cortisone. Typically, a local anesthetic is mixed in the same syringe with the corticosteroid, and both are administered together, into the affected area. The patient had been treated appropriately, with conservative modalities, to alleviate her heel pain. After three months, the patient was only 40% improved, and now shows signs of a potential tarsal tunnel syndrome, with a positive Tinels sign. Final Result: Two of three reviewers determined that a portion of 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 partially overturned. Credentials/Qualifications: Medical professional reviewers number one, two, and three are board certified in podiatry and 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested LINX procedure (CPT code 0392T, laparoscopic anti-reflux surgery)for treatment of his gastroesophageal reflux disease (GERD). Findings:  Two physician reviewers found that the LINX device received U.S. Food and Drug Administration (FDA) premarketing approval for four years, effective 3/22/12. The approved indication was for patients with diagnosed GERD as defined by abnormal pH testing, and who continue to have chronic GERD symptoms despite maximal medical therapy for the treatment of reflux. As noted by in a study, sphincter augmentation with the LINX Reflux Management System provided long-term clinical benefits as demonstrated by reduced esophageal acid exposure, improved GERD-related quality of life, and cessation of dependence on PPIs, with minimal side effects. Patients with inadequate symptom control with acid suppression therapy may benefit from treatment with sphincter augmentation. This patients records support a diagnosis of GERD based on pH recording off PPI therapy, and per charted comments he has not optimally benefited from acid suppression treatment. Although symptomatic for many years, significantly he has not developed endoscopic evidence of esophagitis. From a symptomatic perspective, the patient may be considered medically refractory to acid blocker drugs. However, implantation of LINX in this patients clinical setting places him at significant risk for dysphagia post-LINX implantation given his known esophageal dysmotility. Final Result: The reviewers determined that the requested procedure is 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: Reviewer 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in gastroenterology 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: The patient has requested authorization and coverage for MRI of the left wrist and thumb. Plotkin and colleagues note that the tendons of the wrist are commonly symptomatic and can be torn, infected, or inflamed. The authors note that MRI and ultrasonography are useful tools for evaluating the wrist for possible pathologic conditions including de Quervain tenosynovitis, extensor carpi ulnaris tendinopathy, rheumatoid tenosynovitis, infectious synovitis, tendon tears, hydroxyapatite deposition disease, intersection syndrome, tenosynovial giant cell tumor, and fibroma of the tendon sheath. In this case, the patient has pain in his left wrist and thumb and has failed conservative treatment with wrapping, bracing, and medications. As such, an MRI scan is medically indicated to help provide a definite and accurate diagnosis and allow for appropriate treatment. Therefore, MRI of the left wrist and thumb is medically necessary for the evaluation of this patient.Final Result: The reviewer determined that the requested service 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 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 58-year-old female enrollee requested authorization and coverage of autologous bone marrow transplant (stem cell trasplant) for the treatment of stage IIIA carcinoma of the breast.  The health plan denied the enrollees request indicating that the requested treatment is experimental. Three physician reviewers performed an experimental/investigational Independent Medical Review.  Each of the three physician reviewers concluded that autologous bone marrow transplant (stem cell trasplant) is not likely to be more beneficial for treatment of the enrollees stage IIIA carcinoma of the breast than any available standard therapy.  Because all three physician reviewers concluded that the requested treatment is not likely to be more beneficial for treatment of the enrollees medical condition than any available standard therapy, the review organization upheld the health plans denial.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 62-year-old female who has had a compression fracture of L1 and a right wrist fracture. She was in a great deal of pain after the injury and was unable to sit or stand. She underwent a course of physical therapy before being discharged from the hospital. She has very limited mobility. However, limitation status at time of discharge is unclear. After being discharged, the patient obtained a hospital bed and bedside commode.  The Health Plan has denied reimbursement for this equipment on the basis it was not medically necessary for treatment of the patients condition.The patient did not require a bedside commode per the records provided. Ambulation is an essential part of recovery from a vertebral fracture. Ambulating to the toilet is an important element of recovery. Thus, use of a bedside commode was not medically indicated or in the best interest of the patient. However, patients such as this patient often benefit from use of a hospital bed as the bed aids in mobility and pain management. Vertebral fractures are very painful and patients often require skilled nursing facility care. In this case, use of a hospital bed likely helped avoid a stay in a skilled nursing facility. As such, I have determined that although the bedside commode was not medically necessary for this patient, the hospital bed was medically necessary and should be covered by the Health Plan.As set forth above, I have determined that a portion of the equipment at issue was medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned.
Appeal type: Medical Necessity
Decision: Overturned

The patient is an 11-month-old male with a history of bilateral profound sensorineural hearing loss. The patient had a CT scan, which showed hypoplasia of the cochlea with very small internal auditory canals. The CT scan report indicates there is an absence of cochlear nerves, however, as the patients provider points out the patients responses to ABR testing supports the presence of at least some cochlear nerve fibers. The patients provider has recommended the patient undergo simultaneous bilateral cochlear implantation. The Health Plan has denied authorization for the procedure indicating the patient does not meet criteria for the procedure as he is under the age of one year.Despite the fact that there is some literature showing the value of bilateral cochlear implantation, cochlear implantation performed on both ears simultaneously is not standard of care. Furthermore, there is no peer-reviewed literature demonstrating the benefits of bilateral cochlear implantation in patients such as this patient with severe malformation of the ear. However, it does appear the patient is a candidate for unilateral cochlear implantation in the better ear (as determined by his cochlear implant team). The patient should be re-assessed after the unilateral cochlear implant procedure to determine if he has benefited from the procedure prior to consideration of a second cochlear implant.Based upon the information set forth above, I have determined that although bilateral cochlear implantation is not medically necessary for treatment of the patients medical condition, unilateral cochlear implantation is medically necessary for treatment of the patients medical condition. The Health Plans denial should be partially overturned.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a power wheelchair with full recline and power-elevating leg rests for treatment of the enrollees lymphedema. Findings:  The physician reviewer found that the documentation does not reveal that the requested power mobility device is medically necessary for treatment of this patients lymphedema. Power mobility devices are recommended for use when a patient has a personal mobility deficit that impairs their participation in mobility related activities of daily living (MRADLs) such as toileting, feeding, grooming and bathing in customary locations within the home. The patients condition much be such that it is not able to be ameliorated by a walker, cane or manual wheelchair. This patients documentation indicates that she has a fully functioning power mobility device, she can ambulate within her home with a walker, and she is currently independent with her MRADLs. The records indicate that the patients physical therapist encouraged ambulation daily in the house. A review of the literature reveals that exercise in encouraged for lymphedema management and to aid in weight reduction as obesity can increase lymphedema. Furthermore, per the National Lymphedema Network (NLN), stage 2 or worse lymphedema does not respond to simple elevation alone. Additionally, the patient can elevate her legs on a stool or other object rather than using a power mobility device for this purpose. Thus, the request for a power wheelchair with full recline and power-elevating leg rests is not medically necessary. Final Result: The reviewer determined that the requested equipment 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 physical medicine and rehabilitation with sub-specialty 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.