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

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for applied behavioral analysis (ABA) therapy for treatment of the enrollees fetal alcohol spectrum disorder, attention deficit hyperactivity disorder (ADHD) and behavioral difficulties. Findings:  The physician reviewer found that based on the clinical documentation provided for review, the request for ABA therapy has not been established as medically necessary for treatment of the patients medical condition. There is insufficient support in the peer-reviewed literature for the requested services in this clinical setting. There is some research showing that ABA can be helpful for children with intellectual disability or other behavioral challenges. However, there is a lack of peer-reviewed literature indicating that ABA therapy would benefit the patients diagnoses. 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.  Credentials/Qualifications: The reviewer is board certified in pediatrics with sub-specialty certification in developmental-behavioral pediatrics and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Xolair 150 mg tablets for treatment of her allergic bronchopulmonary aspergillosis. Findings:  The physician reviewer found that there are two main indications for Xolair, severe allergic asthma and urticaria.  There are a few literature reports regarding the use of Xolair for allergic bronchopulmonary aspergillosis, but this is off-label. This patient has a diagnosis of allergic bronchopulmonary aspergillosis, and there is a lack of support for the requested medication in this case.  In this clinical setting, steroids are the primary treatment.  The records indicate that the patient was on a low dose of prednisone, although the records also described a steroid burst.  However, the standard treatment for allergic bronchopulmonary aspergillosis is high-dose prednisone.  More studies are needed to clarify the role of Xolair for the patients 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 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.
Appeal type: Medical Necessity
Decision: Upheld

A 58-year-old male enrollee has requested Promethazine with Codeine cough syrup for treatment of his chronic asthma and chronic obstructive pulmonary disease.  Findings:  The physician reviewer found that ongoing use of Promethazine with Codeine cough syrup for cough suppression is not justified in the medical literature. Specifically, there are no evidence based guidelines that support the chronic use of Promethazine with Codeine cough syrup for cough in patients with COPD for more than episodic therapy longer than three months (Irwin, et al; Bolser). Therefore, the requested Promethazine with Codeine cough syrup is not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for skilled nursing facility services. Chronic leg wounds in the setting of venous stasis can be difficult to heal, with many wounds persisting beyond six months.  The cornerstones of care include compression and keeping wound beds moist to promote autolytic debridement, angiogenesis and formation of granulation tissue. The records in this case indicate that the patients leg wounds were improving very slowly on the treatment regimen, which consisted of topical dressings without requiring skilled nursing services for application, as well as intermittent outpatient visits for debridement. The records do not indicate that the patient required treatments that could not have been provided in the community setting. The prognosis for his clinical course and outcomes would have remained guarded on account of his underlying conditions which included severe congestive heart failure, possible lymphedema and deconditioning, with compromised ability to ambulate.  Ongoing skilled nursing facility level care would not have been expected to marginally improve his clinical course or outcomes over community-based care. The records do not otherwise document services that the patient needed in an inpatient setting that could not otherwise have been delivered in the community setting. Therefore, skilled nursing facility services were not medically necessary for the 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 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the DecisionDx-Melanoma Gene Assay. For cutaneous melanoma stage I-II measuring 0.3 mm, the DecisionDx-Melanoma Gene Assay has been validated as an accurate predictor of five-year metastatic risk. Treatment plans for cutaneous melanoma, including possible adjuvant therapy use, are based upon the individual patients risk of recurrence. The alternative testing for recurrence risk and treatment decision-making is a sentinel lymph node biopsy (SLNB). Low-risk results from the DecisionDx-Melanoma Gene Assay identifies patients who could avoid invasive SLNB. In this case, cutaneous metastases would be difficult to detect from full-body skin screening examination surveillance due to the absence of pigmentation in the tumor. Surveillance with full-body positron emission tomography (PET) scan would involve additional exposure to radiation. The patients tumor is amelanotic melanoma measuring 0.55 mm. In this scenario, the results of the DecisionDx-Melanoma Gene Assay were associated with a low risk of recurrence within five years. This result was likely to spare the patient from undergoing SLNB. For these reasons, the DecisionDx-Melanoma Gene Assay was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Findings:  Two of the three physician reviewers found the DecisionDx-Melanoma Gene Assay was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the services at issue were 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: Physician reviewers 1, 2, and 3 are board certified in dermatology 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 37-year-old female enrollee has requested umbilical artery echocardiography (ECHO), Doppler with color flow add-on, and ECHO of the fetal heart for evaluation of her high risk pregnancy. Findings:  The physician reviewer found that a follow-up ultrasound examination to evaluate fetal growth and anatomy is appropriate in this patient whose anatomic ultrasound was limited by maternal habitus. However, consistent with the Fetal Echocardiography Task Force and American College of Obstetricians and Gynecologists recommendations, there is no indication for fetal echocardiography in this patient without a documented family history of congenital heart disease, concern for fetal cardiac anomalies on prior scan, diabetes or medication exposures. In addition, with no documented risk factors for preeclampsia or fetal growth restriction, there is no medical indication for uterine artery Doppler studies (Sciscione, et al). Therefore, the requested diagnostic procedures are not medically necessary for evaluation and care of this patients pregnancy.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Gel-One (hyaluronic acid) injection in the left knee. Findings: 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 tried and failed other conservative treatments, with the alternative being a total knee arthroplasty. Given the patients limited options and based on the current medical literature, the requested service is medically indicated. Therefore, Gel-One (hyaluronic acid) injection in the left knee is medically necessary for the treatment 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: Medical Necessity
Decision: Upheld

A 42-year-old female enrollee has requested residential treatment services for treatment of substance abuse.Findings:  The physician reviewer found that the patient could have been appropriately treated at an outpatient level of care in a chemical dependency program supervised by a psychiatrist.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Exalgo extended release 12 mg. Findings:  The physician reviewer found that based on current medical literature and in consideration of the presented clinical records, Exalgo is not medically necessary for treatment of this patients medical condition. The medical records have shown the patient to have chronic nonmalignant pain. The current standard of care for chronic pain is treatment in a multidisciplinary practice that includes physical therapy, massage therapy, behavioral therapy, and steroid injections. Based on a study there are Well-established guidelines for routine back pain stress conservative management, including use of nonsteroidal anti-inflammatory drugs (NSAIDs) or acetaminophen and physical therapy, but avoiding early imaging or other aggressive treatments, except in rare cases, such as acute neurologic compromise or other red flags, including a history of malignant neoplasms. Similar findings are reflected in a report which states that Conservative decisions in the treatment of degenerative disc disease are based on interventions made for patients with chronic low back pain (LBP). Furthermore, these therapies work best in a multidisciplinary rehabilitation context. Pain medication is needed for most patients with degenerative disc disease, and surgery may be needed for a minority only. There are a variety of anticonvulsants and antidepressants that are considered adjunctive to pain management therapy. If there is poor response to conservative therapy, then surgery should be considered. The medical evidence shows that high dose opioids are associated with a high risk of dependence and tolerance. Therefore, they are not recommended in this clinical setting. Accordingly, Exalgo ER 12 mg is not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested medication regimen 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 anesthesiology with sub-specialty certification in pain medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 43-year-old woman with a body mass index (BMI) of 45. In addition, the patient has multiple comorbid conditions. The patient has failed attempts at standard weight loss modalities. The submitted records indicate the patient has undergone three psychological evaluations to determine her suitability for weight loss surgery with varying results. The results of the first two psychological evaluations indicated the patient was not an appropriate candidate for weight loss surgery. However, a third psychological evaluation, which appears to be the most recent, determined the patient met psychological criteria for weight loss surgery. At issue is whether the requested surgery is medically necessary for treatment of the patients condition.The patient meets national medical necessity criteria for weight loss surgery based upon her BMI of 45 and documented comorbid conditions. In addition, the results of a psychological consult in August 2005 demonstrate the patient is currently relatively stable and has the emotional capacity to undergo weight loss surgery. As such, there is sufficient clinical documentation of need and compliance to warrant bariatric surgery in this case. 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: Medical Necessity
Decision: Overturned

A 26-year-old female enrollee has requested Lyrica 150mg twice daily for treatment of fibromyalgia and depression. Findings:  The physician reviewer found that since fibromyalgia is now an FDA approved indication for Lyrica, and given that this patient has already been receiving Lyrica with significant benefit, continued use of the medication at standard doses (which typically range from 300mg to 450mg daily) is medically appropriate and clinically indicated.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for oral/facial myofunctional therapy and myofascial release via the stecco fascial manipulation technique for treatment of the enrollee, who has a history of neck pain and tongue pain. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services. This patient has been diagnosed with atypical facial pain/myofascial pain. The mainstay for patients with myofascial pain and a history of temporomandibular joint disorder includes oral appliance therapy. Physical medicine techniques, such as massage, ultrasound and iontophoresis have been used in the past with some success. However, studies are lacking to support fascial manipulation for myofascial pain dysfunction. All told, the requested for oral/facial myofunctional therapy and myofascial release via the stecco fascial manipulation technique 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.  Credentials/Qualifications: The reviewer is board certified in oral and maxillofacial 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: Upheld

Nature of Statutory Criteria/Case Summary:   An enrollee has requested continued skilled nursing facility services (physical therapy, occupational therapy and speech therapy) for treatment of his medical condition. Findings:  The physician reviewer found that based on the clinical documentation submitted for review, the medical necessity for continued skilled nursing facility services (physical therapy, occupational therapy and speech therapy) has not been established. According to the documentation submitted for review the patient had a stroke and has been treated at the skilled nursing facility level of care. After receiving skilled nursing facility level therapies, the patient made some slow progress in aspects of self-care while other aspects of self-care and functional mobility showed no improvement. Continued skilled nursing facility level therapies are not supported by the literature or by the patients recovery trajectory. He may benefit from some degree of outpatient therapy, but skilled nursing facility level therapy is not medically necessary. The nursing note does not show a need for inpatient level skilled nursing care. The patient does have basic care needs that can be addressed by home health aides. As such, skilled nursing facility services (physical therapy, occupational therapy and speech therapy) was not and is not medically necessary.  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 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.
Appeal type: Medical Necessity
Decision: Upheld

A 48-year-old male enrollee has requested an electric scooter/wheelchair for treatment of his herniated lumbar disc with foot drop.  Findings:  The physician reviewer found that the records reviewed do not substantiate the presence of impairments that would preclude this patient from accomplishing his MRADLs within the home with the use of a right ankle foot orthosis and cane or walker, or with a manual wheelchair. The patient is not documented to have any significant neurological or musculoskeletal impairment or pathology affecting the upper limbs. In addition, he does not have any evidence of cardiovascular or pulmonary condition that is severe enough to preclude the use of a cane, walker or manual wheelchair. On the contrary, the patient has multiple chronic medical conditions that would benefit from increased physical activity. Consistent with the recommendations published by Keyser and colleagues, his limb pain and lack of strength or endurance should be treated with appropriate exercise and training, not with disuse. Overall, a power mobility device is not medically necessary for this patient applying the Medicare guidelines as reported by Dicianno and Tovey. In the absence of the requested equipment this patient would not be confined to a bed or chair. This determination is further supported by the occupational therapy evaluation on the date in question, which concluded that the patient did not qualify for powered mobility because he could safely ambulate with a cane or walker.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting authorization and coverage of Prolia. Findings:  The physician reviewer found that the enrollee has a medical history of osteoporosis, recurrent gastric ulcer, and rectal cancer. She was treated with Ibandronate and Fosamax for osteoporosis. Her physician indicated these were ineffective.  An esophagogastroduodenoscopy (EGD) showed an antral ulcer and bulbar diverticulum for which proton pump inhibitors were prescribed. Her symptoms persisted and Carafate was prescribed. She had a bone density study which confirmed osteoporosis. Prolia injections were prescribed. The provider explained to the enrollee that bisphosphonates were contraindicated due to the enrollees severe reflux and ulcers. The health plan has denied coverage for the Prolia injections as not medically necessary. They indicate the enrollee needs to have tried treatment with a bisphosphonate, as studies do not show treatment with Prolia works better than treatment with a bisphosphonate. The medical literature for Boniva, a bisphosphonate, indicates Boniva should not be given to patients with active upper gastrointestinal disease and should be discontinued in patients who develop any symptoms of esophagitis. This enrollee has active upper gastrointestinal symptoms in spite of proton pump inhibitor therapy and Carafate. Under these circumstances, Prolia is a recommended alternative for the treatment of osteoporosis and is a medically necessary treatment in patients with active upper gastrointestinal symptoms.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 internal medicine and gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or similar medical condition.