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

The parent of a 17-year-old male enrollee has requested a magnetoencephalography (MEG) for an evaluation of the enrollees intractable complex partial seizures. Findings:  Three physician reviewers found that this patient has pharmaco-resistant epilepsy as multiple medications have failed. He has distorted brain anatomy due to a prior craniotomy and may have functional distortion due to neuroplasticity. Successful epilepsy surgery offers the possibility of improved seizure control which is not likely with additional medication trials. Prior diagnostic studies including magnetic resonance imaging (MRI), PET, and EEG have not adequately defined the seizure focus. A review of the medical literature reveals that MEG can assist in localizing epileptic foci, including deep ones that escape standard EEG. It can also help when MRI scans show a lesion discordant to EEG findings, and can map critical normal areas of brain function to optimize surgical planning. It may allow minimization of invasive testing and associated risks. MEG is approved by Medicare in similar circumstances, and a policy statement from the American Academy of Neurology (AAN) supports its use in presurgical epilepsy planning. It is becoming a generally accepted diagnostic tool at major epilepsy surgery centers due to its ability to allow identification of deep seizure foci.
Appeal type: Medical Necessity
Decision: Overturned

An enrollee has requested authorization and coverage for the weight loss medication Saxenda.  Findings:  The physician reviewer found that Saxenda is approved as an adjunct to a reduced-calorie diet and increased physical activity for chronic weight management in adult patients with an initial body mass index of 30 or greater or 27 or greater in the presence of at least one weight-related comorbid condition.  The initial management of individuals who would benefit from weight loss is a comprehensive lifestyle intervention: a combination of diet, exercise, and behavioral modification.  The patient had been tolerating Saxenda and had lost 16 pounds while on the medication.  Given the documentation that supports the patient has obesity with a body mass index of 40.75, has had previous treatment with diet and exercise without successful weight loss, and has had success with weight loss while taking Saxenda. Final Result: the physician reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. The physician 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: Experimental/Investigational
Decision: Overturned

The parent of a 6-year-old female has requested coverage for speech therapy twice per week for 45 minute sessions for 6 months for treatment of her acquired auditory processing disorder.  Findings:  Three physician reviewers found that this patient has a diagnosis of central APD. The standard of care as reported by Musiek and Chermak in the treatment for patients with APD is speech therapy and modification of the listening environment. These modalities are also encouraged by Moore in his 2006 article who states that, the management of childhood APD has been mainly achieved through modifications to the acoustic environment and sound delivery to the ears, and through auditory and speech training. This patient has demonstrated improvement with speech therapy services already provided and it is important for this treatment to continue to address his individual issues. Accordingly, the requested speech therapy is likely to be more beneficial than any standard alternative and should be approved.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting authorization and coverage for Hyaluronan (Synvisc) injections in the right knee, and reimbursement for a knee brace. The enrollee has a history of chronic knee pain, which has worsened over the last few years. The pain is associated with swelling, clicking or popping, instability and weakness. The note reports prior treatment included anti-inflammatory medications, physical therapy, and four injections, type not specified, four months prior. A progress note reports a magnetic resonance imaging scan showed right knee tricompartmental osteoarthritis. The physician recommended weight loss, as the enrollees body mass index was 45, and Synvisc injections. This enrollee is of a relatively young age and demonstrates significant tricompartmental arthritis that has been symptomatic. After the failure of primary measures, viscosupplementation may be considered and utilized as an evidence-based, non-operative treatment measure, particularly alongside weight loss and bariatric measures. An offloader knee brace is preferentially indicated for individuals with unicompartmental arthrosis. However, this enrollee demonstrates significant radiographic and symptomatic degenerative disease in both the patellofemoral joint and lateral compartment, thereby limiting the potential efficacy of offloading into the lateral compartment.  Similarly, custom braces are indicated where explicitly stated for abnormal thigh to calf ratio or other specific extenuating factors, which are not stated in this request.Final Result: The reviewer determined that the requested services are partially medically necessary for the treatment of the enrollees medical condition. The Hyaluronan (Synvisc) injections were found medically necessary, but the offloader knee brace was not found medically necessary. Credentials/Qualifications: The physician 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 30-year-old female enrollee has requested Cymbalta 20mg for treatment of her behavioral health condition.  Findings:  The physician reviewer found the submitted documentation fails to establish the medical necessity of the requested medication. The record indicates that the patient has tried one dose of Effexor and discontinued it because of the reported side effects of nauseous, nervous, tired and trouble sleeping. According to the manufacturers prescribing information, Cymbaltas common side effects include nausea, dizziness, somnolence and fatigue. Both Effexor and Cymbalta are the same class and are likely to produce the same side effects. Therefore it is likely that the patient would experience the same issues with Cymbalta that she experienced with Effexor. In fact, most patients do experience these side effects at first, but they generally abate after about a week, and certainly within a few weeks.  Therefore, it is not medically necessary for the patient to receive Cymbalta based on the side effects experienced with one single dose of Effexor. Thus, the requested medication is not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

The parent of an eight-year-old male has requested vision therapy for treatment of the enrollees convergence insufficiency.  Findings:  The physician reviewer found that convergence insufficiency is a binocular vision disorder successfully treated with vision/orthoptic therapy. Convergence insufficiency is a condition presenting with an exophoria at near, orthophoria to low exophoria at distance, a reduced near point of convergence, reduced positive fusional vergence, and a low AC/A ratio. Convergence insufficiency often presents with symptoms of blurred vision at near, discomfort, strain and fatigue associated with near tasks. The goal of vision therapy is to stimulate and normalize vergence abilities. The endpoint of vision therapy for these conditions is when the patient is able to maintain clear, single binocular vision with a series of orthoptic tasks. The literature provides a solid base of research supporting vision therapy as an effective treatment mode for accommodative and convergence deficiencies.
Appeal type: Experimental/Investigational
Decision: Upheld

Physician 1: The patient is a 28-year-old female with a history of Achilles tendonitis. She has attempted physical therapy without success. Her provider has recommended an RS-4i stimulator for the patient. The Health Plan considers this experimental and has denied authorization.There is no class I literature supporting the use of the RS-4i sequential stimulator in cases of Achilles tendonitis. This is considered an experimental treatment and is not the standard of care. Furthermore, there are available therapies with established efficacy for treatment of this patients condition. Therefore, because of the lack of evidence supporting the efficacy of the requested RS-4i sequential stimulator, I have determined the requested equipment is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld.Physician 2: The patient is a 28-year-old female with pain and tightness at the Achilles/gastrocnemius junction consistent with Achilles tendonitis. Her condition has not responded to numerous treatment modalities, which have included taping, soft tissue mobilization, ultrasound with phonophoresis, electrical stimulation with iontophoresis, and a home exercise program. She has been unable to return to her full range of activities. Use of an RS-4i sequential stimulator has been requested by the patients treating physician with the Health Plan denying authorization.There are many physical modalities currently utilized in the management of tendon disorders. Ultrasound, phonophoresis, electrical stimulation, and iontophoresis are routinely prescribed in clinical practice for patients with tendonitis and tendonosis. Scientific evidence on the effectiveness of these standard physical modalities is sparse and controversial. In the case of inferential stimulation, there is an absence of scientific evidence demonstrating that it is more effective than standard available therapies. Therefore, I have determined the requested equipment is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld.Physician 3: The patient is a 28-year-old female with Achilles tendonitis. She has attempted a number of treatments without sustained benefit. A request has been made for an RS-4i stimulator.The requested equipment is neither required nor necessary for treatment of the patients condition. Achilles tendonitis is treated with rest, medication, physical therapy, home exercise, and may include ultrasound and electrical stimulation with a TENS unit. There is no prospective study demonstrating any advantage of an RS-4i stimulator over any other electrical stimulation product.Based upon the information set forth above, I have determined the requested equipment 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.
Appeal type: Experimental/Investigational
Decision: Overturned

A 61-year-old female enrollee has requested magnetic resonance imaging (MRI) of the left breast for treatment of her dimpling in the lower inner quadrant of the left breast seen on mammogram.  Findings:  Two physician reviewers found that review of the peer-reviewed literature yielded support for the utility of breast MRI for evaluation of inconclusive findings following a standard evaluation including physical exam, mammography and breast ultrasound. As noted by the American College of Radiology (ACR) guidelines, MRI is useful for lesion characterization when other imaging examinations, such as ultrasound and mammography, and physical examination are inconclusive for the presence of breast cancer, and biopsy could not be performed (e.g., possible distortion on only one mammographic view without a sonographic correlate). Similarly, the American Society of Breast Surgeons recommend breast MRI for further evaluation of suspicious clinical findings or imaging results that remain indeterminate after complete mammographic and sonographic evaluations combined with a thorough physical examination. This patient has dimpling of a portion of the left breast that is often a clinical presentation of breast cancer. The patients mammogram and breast ultrasound were normal and it is not possible to perform a biopsy as there is no focal abnormality noted on physical exam, mammography or breast ultrasound. Overall, this patient has inconclusive findings following standard work-up for which the requested breast MRI is likely to be more beneficial for evaluation and treatment than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld

A 38-year-old male enrollee has requested for a Sara 3000 electric patient lift for treatment of his Beckers muscular dystrophy.  Findings:  The physician reviewer found that a Hoyer lift or other patient transfer system that supports the patients entire body during transfers would be appropriate for this patient and is consistent with the recommendations by the occupational therapist. For these reasons, the requested device is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 60-year-old female with an apparent history of chronic fatigue syndrome.   She has been followed by an infectious disease specialist for several years, initially for a chronic fungal sinusitis in 2001. The patient consulted with her provider again in October 2004 and the record notes chronic enteroviral infection and refers to the use of doxycycline for suppression. The patients laboratory results are generally within normal limits except for elevated serum glucose levels and Chlamydia pneumoniae antibody levels which are elevated in the range of 1:256 to 1:1056. A footnote from the laboratory indicates that the kit used for these tests is not FDA approved. The patients complaints include fatigue, difficulty with sleep and unspecified gastrointestinal problems. The patients provider recommended Pegasys and Actimmune therapy and the patient is now requesting reimbursement for the treatment received. The Health Plan denied the requested reimbursement based upon a determination that the Pegasys and Actimmune therapy was not medically necessary.There is no convincing data in the medical literature to substantiate the theory that Chlamydia pneumoniae infection can cause chronic fatigue. While the elevated C. pneumoniae serologies cannot be readily explained, further scrutiny of these results would be appropriate to fully assess their meaning. Similarly, there is no support in the literature for the treatment of this condition with interferons, which are associated with significant effects. Neither Pegasys nor Actimmune are approved by the FDA for this application. Therefore, I have determined the therapy at issue was not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for acute inpatient psychiatric treatment for treatment of the enrollees behavioral health conditions. Findings:  The physician reviewer found that in order to objectively determine if the patient meets criteria for length of stay, the records were analyzed based on the Level of Care Utilization System (LOCUS) criteria. This is an accepted, national standard for determining the appropriate level of care for adults. In terms of risk of harm, the records support a score of 4.  The patient has a history of suicide attempt. She has chronic suicidal ideation and can be impulsive. It was noted that the patients suicidal ideation had improved, although her suicidal thoughts remained present.  With regards to functional status, the records support a score of 4.  The patient isolated from staff and the milieu. She did not participate in groups. She had a consistent failure to maintain her personal hygiene and appearance. She is unable to work due to her mental illness. With regards to medical/addictive/psychiatric comorbidity, the records support a score of 3. The patient has a significant comorbidity of schizoaffective disorder, posttraumatic stress disorder, and borderline personality disorder. She also has migraines and has a history of substance abuse. In terms of recovery environment, the records supports a score of 3.  The patient has a moderately stressful environment. The patient just broke up with her boyfriend. She also reported having a conflictual relationship with her mother.  With regards to level of support, the records support a score of 4.  The patient has very limited sources of support. In terms of treatment history, the records support a score of 3. The documentation noted equivocal response to treatment and recovery. The ECT series received inpatient was equivocal and did not achieve complete remission of symptoms. With regards to engagement and recovery status, the records support a score of 4. The patient is minimally involved in her treatment. She relates poorly to treatment providers and isolates from staff.  Therefore, the records support a total score of 25. Thus, the patient would meet criteria for a residential treatment program. Per the submitted documentation, the patient is able to be treated in a less restrictive environment in a residential treatment center setting. Therefore, acute inpatient psychiatric treatment was not and is not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the services at issue were not and are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 59-year-old female enrollee has requested medication Provigil for treatment of major depressive disorder.  Findings:  The physician reviewer found that there is significant clinical empirical evidence of the importance of Provigil in cases of major depressive disorder in conjunction with approved antidepressants, such as Lexapro and Wellbutrin.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 53-year-old woman with osteoarthritis who has undergone a series of Synvisc injections on several occasions in order to alleviate her knee pain. A request has been made for repeat Synvisc injections. The Health Plan has denied this request on the basis that the requested injections are not medically necessary for treatment of the patients knee pain.The patient has achieved significant pain relief with Synvisc. There have been no documented side effects or other complications from the therapy. She is attempting to avoid knee replacement surgery at this time. Repeat Synvisc injections are medically reasonable and appropriate at this time to alleviate pain and postpone surgical intervention. Therefore, I have determined the requested injections are medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Upheld

A 40-year-old female enrollee requested authorization and coverage for a vitrectomy.  The health plan has denied this request indicating that the requested procedure is considered experimental for treatment of the enrollees pseudoxanthoma.Three physician reviewers performed an experimental/investigational Independent Medical Review. Because all three-physician reviewers concluded that the requested therapy is not likely to be more beneficial for treatment of your medical condition than any available standard therapy at this time, the Health Plans denial has been upheld.
Appeal type: Medical Necessity
Decision: Overturned

The parents of an 18-year-old female enrollee requested authorization and coverage for breast surgery for treatment of the enrollees Scoliosis.  The health plan has denied this request indicating that the requested surgery is cosmetic in nature and not medically necessary for treatment of the enrollees Scoliosis.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer overturned the health plans denial on the basis that the requested procedure is reconstructive in nature and is medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

A 60-year-old female enrollee has requested an endoscopy for the treatment of her gastroesophageal reflux disease (GERD). Findings:  The physician reviewer found that this patient has had multiple EGD exams, which were all negative. Another EGD in this case is not likely to yield any data that will alter the management of this patients condition. In the absence of any evidence that an EGD would affect the medical management or outcome of this patients condition, the clinical utility of another EGD in this setting has not been established. As such, the proposed study is not clinically indicated or necessary for this patient.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for a home oxygen tank.Current standards-of-care and best practice guidelines support prescribing home oxygen for patients with hypoxemia at or below oxygen saturation level of 88%. In this case, the patient has no evidence of reproducible exertional hypoxemia. Although there are reports of oxygen saturation of 78% with ambulation, these findings could have been spurious, particularly in the setting of a poor quality plethysmograph. Moreover, repeat ambulatory oximetry on two separate occasions showed normal oxygen saturation during ambulation up to 200 feet. The submitted documentation fails to demonstrate the medical necessity of the requested equipment at this time. Therefore, a home oxygen tank is not medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that 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 internal medicine with sub-specialty certification in pulmonary disease 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.