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

A 34-year-old male enrollee has requested a Dexcom continuous glucose monitoring system (CGMS) and the sensors for treatment of his type I diabetes.  Findings:  The physician reviewer found that there is substantial support in the peer reviewed medical literature for the use of continuous glucose monitoring in the treatment of type 1 diabetes. The current American Diabetes Association (ADA) and American Association of Clinical Endocrinology (AACE) guidelines recommend the use of CGMS for patients with brittle diabetes mellitus type 1 and hypoglycemia unawareness. The use of CGMS was associated with improved glycemic control in adults over 25 years old with type 1 diabetes (Juvenile Diabetes Research Foundation) and with reduced time spent in hypoglycemia (Battelino, et al.). Although CGMS is an evolving technology, the available data in the peer reviewed medical literature suggests that in patients who are motivated to wear it most of the time, it may be particularly useful in those with hypoglycemia unawareness and/or frequent episodes of hypoglycemia. This patient is on the insulin pump, has wide glucose fluctuations, hypoglycemia unawareness, and is very motivated to use CGMS for self-management of his diabetes. The requested Dexcom CGMS will help this patient and his provider to determine his insulin pump settings with more precision and it will help prevent dangerous blood glucose fluctuations and hypoglycemic events. Therefore the requested Dexcom CGMS is medically necessary and appropriate for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for lidocaine 5% 50 gm (60 day supply with one refill). In a randomized controlled clinical trial, researchers evaluated pain control during vulvar biopsy after treatment with either application of 5% lidocaine-prilocaine cream or injection of 1% lidocaine. The authors found that, Patients randomized to lidocaine-prilocaine had a significantly better experience than those receiving injected lidocaine. The authors concluded that topical analgesics such as lidocaine 5% ointment can safely and effectively improve perineal pain. Researchers evaluated the effects of lidocaine-prilocaine cream versus local infiltration of lidocaine during repair of perineal trauma after vaginal delivery. The authors found that, Topical lidocaine-prilocaine cream gives comparable results in reducing pain during perineal repair after vaginal delivery. In this case, the patient has chronic pelvic and perineal pain. Her provider recommended lidocaine 5% ointment. The current medical literature supports treatment with anesthetic ointments as safe and effective for use in the pelvic and perineal areas. Given these findings, the requested lidocaine 5% 50 gm (60 day supply with one refill) is medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested medication 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 anesthesiology with subspecialty certification in pain management 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 27-year-old female enrollee has requested reimbursement for residential sub-acute rehabilitation provided for five days for treatment of the enrollees alcohol dependence.   Findings:  The physician reviewer found that this is a complex case with significant affective and addictive influences.  Per the American Psychiatric Association guidelines, residential treatment is indicated primarily for individuals whose lives and social interactions have come to focus exclusively on substance use and who lack sufficient motivation or social supports to remain abstinent in an ambulatory setting.  In this patients case, she had failed a lower level of care.  Although not a formal program, her community-based, recovery-oriented treatment plan encompassed the core elements of partial hospitalization and intensive outpatient care.  Despite this comprehensive plan, the patient was unable to remain abstinent in the ambulatory setting.  Further, the quantity of alcohol consumption, coupled with co-ingestion of hypnotics and psychotropic medications that can lower the seizure threshold, placed her at risk for a complicated detoxification.  The current medical evidence supports sub-acute residential rehabilitation in this clinical situation.  All told, the residential sub-acute rehabilitation provided was medically indicated.
Appeal type: Experimental/Investigational
Decision: Upheld

A 69-year-old female enrollee has requested for an electron beam computed tomography for evaluation of her hyperlipidemia. Findings:  Two physician reviewers found that there is no documentation of known heart disease or cardiac symptoms. An electron beam computed tomography was ordered to evaluate the need for more aggressive treatment of hyperlipidemia.In this circumstance, risk factor modification is indicated and should be implemented according to evidenced-based guidelines. In the case of cholesterol management, nationally accepted guidelines have been published and updated periodically. These guidelines do not recommend the routine use of or screening with electron beam computed tomography, largely because the incremental value of electron beam computed tomography in improving outcome above that which can be obtained with standard risk factor profiling has not been established.
Appeal type: Medical Necessity
Decision: Upheld

A 19-year-old male enrollee has requested testosterone therapy (at standard doses) for the treatment of his stated hypogonadism. Findings:  The physician reviewer found that in order to preserve future fertility, the patient should slowly taper and retest his hypothalamic-pituitary-testicular axis. Body builders who take too much testosterone turn off their ability to make their own testosterone as well as sperm.  The former is what the patient, did as evidenced by his very high levels of testosterone and suppressed levels of LH, the usual testicle testosterone stimulator. The requested therapy is not medically appropriate or indicated.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the blood test, advanced lipoprotein testing for evaluation of the enrollee, who presented with heart palpitations.  Findings:  The physician reviewers found that The patient no prior history of heart disease. She presented with four to five week history of intermittent palpitations and anxiety. Her blood pressure, pulse and cardiopulmonary examinations were normal. The patients resting electrocardiogram (EKG) was also normal. The patients provider referred the patient for blood testing including chemistries, standard lipids profiles, advanced lipoprotein studies and advanced coagulation and metabolic studies.  Per the Health Plan, the services at issue were investigational for the evaluation of this patient. The medical literature does not support the superior efficacy of the services at issue in this clinical setting. The records did not indicate that this patient has a history of coronary artery disease. There were no other significant risk factors for cardiovascular disease. Based on her young age, female gender, and relatively normal cholesterol levels, normal blood pressure and no other risk factors for cardiovascular disease, her calculated risk of heart disease or stroke over the next ten years is extremely low (0.1%). She has had recent intermittent palpitations associated with anxiety and stress but no symptoms of angina, shortness of breath or other symptoms of obstructive cardiovascular disease which would be associated with elevated lipids. The patient also has no indication for pharmacologic therapy for cholesterol reduction based on her symptoms or a standard risk profile. In this instance, the patients standard risk profile is extremely low and the symptoms (intermittent palpitations associated with stress) are also not consistent with obstructive cardiovascular disease. Therefore, the advanced lipoprotein testing was not likely to be more beneficial than the standard evaluation of risk of heart disease in this patient. Final Result: All three reviewers determined that the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewers number one, two, and three are board certified in internal medicine with sub-specialty certification in cardiovascular disease 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

A 48-year-old male enrollee requested authorization and coverage for an endorectal MRI every 12 months.  The health plan has denied this request indicating that the requested testing is considered experimental for treatment of the enrollees medical condition.Three physician reviewers performed an experimental/investigational Independent Medical Review. All three-physician reviewers concluded that the requested services are not likely to be more beneficial for treatment of your medical condition than any available standard therapy.  Because all three-physician reviewers concluded that the requested services are not likely to be more beneficial for treatment of your medical condition than any available standard therapy, the health plans denial has been upheld
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 15-year-old female who has two keloids, which have progressively enlarged and are occasionally painful. She is seeking removal of the keloids. She has been evaluated by a dermatologist who has agreed to surgical removal of the keloids and Kenalog injections. The Health Plan has denied authorization for these procedures on the basis that they are considered cosmetic in nature and not medically necessary.The patient has large, disfiguring keloids, which have become painful. Therefore, there is a functional component to the requested procedures. Furthermore, the requested procedures are appropriate for treatment of the patients condition. Because correction of the patients condition does have a functional component, I have determined the requested procedures are medically necessary for treatment of the patients condition. Therefore, the Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 44-year-old male with a history of persistent musculoskeletal pain. He has been seen by two orthopedists and a podiatrist, and has evidence of chondromalacia patellae as well as plantar fasciitis. Efforts to control his symptoms have failed, including trials of NSAIDs. The patients primary care physician (PCP) has referred the patient to a rheumatologist. The Health Plan has denied authorization for the referral on the basis it is not medically necessary for treatment of the patients musculoskeletal pain.Review of the submitted evidence indicates the requested referral is medically appropriate and indicated. Two orthopedists and a podiatrist, along with the patients PCP have been unable to control the patients symptoms. The PCP has explicitly acknowledged that more specialized help is needed as he has not been able to resolve the patients symptoms. The occurrence of normal labs do not necessarily mean there cannot be an inflammatory condition present; patients with spondylarthropathies often present with plantar fasciitis and normal labs, while hypermobility syndromes and fibromyalgia are expected to present with normal labs. A rheumatologist is the only specialist experienced in sorting out these possibilities. Whether this patient is found to have an inflammatory or systemic cause for his symptoms, his previous physicians have been unable to manage the patients problem. Rheumatologists are experienced in the use of various anti-inflammatory options (such as hydroxychloroquine, tetracyclines or colchicine) as well as the management of pain-related syndromes such as fibromyalgia and myofascial pain. As other providers have not succeeded in controlling this patients symptoms, there is potential a rheumatologist may be able to help this patient. Therefore, I have determined that the requested referral is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Upheld

A 48-year-old female enrollee has requested cancer screening blood tests (CPT codes 81294, 81295, 81297, 81298, 81300, 81317 and 81319) for evaluation of her cancer.  Findings:  Two physician reviewers found that in this patients case, the requested testing is not likely to be more beneficial than other methods of evaluation.  The National Comprehensive Cancer Network does not recommend screening for Lynch syndrome in unaffected individuals with a family history of cancer, unless the diagnosis is already confirmed in the family, and the particular mutation is known.  Alternatively, if a family history is suggestive of the presence of Lynch syndrome, and no affected member is available for testing, it may be appropriate under certain circumstances to test an unaffected individual.  Per the current medical evidence, in order to warrant genetic testing, a minimum of three first-degree relatives must be affected with a hereditary nonpolyposis colorectal cancer (HNPCC), and at least one relative should have been diagnosed prior to age 50.  Since these conditions do not apply in this case, the requested cancer screening blood tests are not likely to be of greater benefit than other modalities for evaluating this patient.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 16-year-old female enrollee has requested sub-acute residential psychiatric treatment for the treatment of the enrollees major depression, recurrent, parent/child relational problem, history of attention deficit/hyperactivity disorder, generalized anxiety disorder and eating disorder. Findings:  The physician reviewer found that this patient required further time in residential treatment to more fully integrate the improvements she was beginning to make at that time. Premature discharge may have engendered a regression in the patients symptoms. Of note is her somewhat fragile character, the nature of her relationship with her family and her need to gain better internal controls to function more adaptively outside the residential setting. Accordingly, sub-acute residential psychiatric treatment services provided were medically indicated and appropriate. However, toward the end of her stay, the records suggest that her improvements were greater. Thus, the patient could have been successfully and safely treated at a lesser level of care toward the end of her stay.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 63-year-old female with a history of degenerative disc disease as well as degenerative arthritis of the lumbar spine. She underwent discectomies at L4-5 and L5-S1. Following surgery, the patient has apparently had persistent or recurrent symptoms with lumbar pain and radiating pain to both legs. Treatment with ibuprofen provided no relief at 600mg and Celebrex 200mg was started in November 2003. This was said to provide greater benefit, with improvement in radiating pain but persistence of right buttock pain. The submitted information indicates that the patient is sensitive to medications but this is not documented in the provided clinical records. Nor do the submitted records note prior use of NSAIDs other than ibuprofen. The patient has requested authorization for Celebrex. The Health Plan has denied her request.Given the patients history of degenerative disc disease and degenerative joint disease of the spine, MRI documentation, history of discectomies, and continuing symptoms, the use of anti-inflammatory agents is both appropriate and medically necessary. In this context, the use of Celebrex is appropriate, given its reported effectiveness and lack of side effects in this patient. This is particularly true given the likely need for long-term treatment for degenerative spinal problems, which are not likely to resolve. However, there is no evidence that Celebrex or other Cox-II inhibitors are more effective than traditional NSAIDs. The advantage of Cox-II inhibitors lies in their lower incidence of symptomatic or dangerous GI effects, such that patient compliance is greater, leading to an overall greater net benefit over time (their lack of platelet inhibition offers an advantage for patients requiring anticoagulant therapy, as well). No evidence has been submitted indicating that the patient has had significant GI history, required long-term steroid treatment, or has failed NSAIDs other than ibuprofen. As such, I have determined that the use of Celebrex is not medically necessary for treatment of the patients medical condition at this time. The Health Plans denial should be upheld at this time. However, the patient should receive trials of up to two relatively GI-safe NSAIDs (such as nabumetone and etodolac) to determine if the patients response is equal to that with Celebrex, with equal tolerability. If either the benefit is less or the degree of tolerability is less, then the patients request for Celebrex should be reconsidered.
Appeal type: Medical Necessity
Decision: Overturned

The patient is an 11-year-old male with idiopathic short stature that may be the result of familial short stature combined with a constitutional delayed adolescence. The patients mother is 410 tall and his father is 54 tall, resulting in a mid-parenteral height of 53.5. His bone age was 9 years and 0 months at the age of 10 years and 10 months, and he was near 48 inches in height at that time, which would give a predicted height near 54, his mid-parenteral height potential. His growth has been well below the third percentile. There have been several IGF-1 levels performed in the low range for age and stage of sexual development, but he had one growth hormone level above 10 after provocative testing. The patient had normal thyroid tests and celiac disease was ruled out. He appears to have been followed by an endocrinologist.At issue is whether growth hormone therapy is medically necessary for treatment of the patients medical condition.The Food and Drug Administration (FDA) has recently approved growth hormone for the treatment of idiopathic short stature as a medically indicated therapeutic intervention to promote growth velocity and final adult height. Based on the FDA criteria, the patient is an appropriate candidate for growth hormone therapy. It is likely that the patient will respond well to growth hormone in that his IGF-1 levels have been consistently low. Positive interval growth responses would be required to continue therapy until epiphyseal fusion.Based upon the information set forth above, I have determined the requested therapy is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

A 62-year-old female enrollee has requested for Aciphex 20mg/day for treatment of her GERD. Findings:  The physician reviewer found that pharmacologic therapy for gastroesophageal reflux disease (GERD) continues to focus on optimizing acid suppression. Proton pump inhibitors (PPIs) continue to be the backbone of therapy in optimizing acid suppression, providing excellent relief of symptoms and healing to erosive as well as non-erosive esophagitis. For the most part, all PPIs are equivalent in their efficacy to control acid secretion. Inter-patient variability of the efficacy has been seen. However, milligram for milligram, all drugs in this class appear comparable in their effects clinically as human studies have not revealed significant differences in their effects with regards to clinical or endoscopic end points or side effects profile.
Appeal type: Medical Necessity
Decision: Upheld

A 47-year-old male enrollee has requested a colonoscopy for screening of colon cancer. Findings:  The physician reviewer found that the patient is at average risk for developing cancer and, as such, a colonoscopy every 10 years is medically appropriate as long as he is asymptomatic.
Appeal type: Experimental/Investigational
Decision: Upheld

A 43-year-old female enrollee has requested for laser destruction of cutaneous vascular lesions for treatment of  her rosacea. Findings:  Three physician reviewers found that there is a lack of studies suggesting that the requested service would be beneficial for the popular/pustular component of rosacea.
Appeal type: Medical Necessity
Decision: Upheld

A 65-year-old male enrollee has requested a mandibular advancement device (oral appliance) for treatment of his moderate sleep apnea.  Findings:  The physician reviewer found that although the use of oral appliances is acceptable for patients with mild to moderate obstructive sleep apnea, CPAP therapy is superior in patients with severe obstructive sleep apnea. Additionally, even in patients with less severe disease, CPAP is superior to oral appliances. It provides a superior reduction of the AHI, improvement in sleep efficiency, and a greater reduction of the arterial oxygen desaturations. This patient has not had a reasonable attempt at using CPAP.  All told, in this patients case, the medical necessity of a mandibular advancement device (oral appliance) has not been established.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:   An enrollee has requested an epidural steroid injection and an epidurogram for treatment her medical condition.   Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of a portion of the requested services.  In this patients case, the requested epidural steroid injection is medically indicated.  The medical records document spinal radicular pain.  In this case, the patient had the epidural steroid injection previously and the provider documented a positive response from that injection.  However, there is a lack of support for the requested epidurogram in this patients case.  The patients MRI scan previously was negative for any neural compromise and the epidural steroid injection done subsequently already included an epidurogram.  There is no rationale supporting why an epidurogram would need to be repeated as the patient has a return of symptoms and had previously responded to the epidural steroid injection.  All told, the requested epidural steroid injection is medically necessary for the treatment of this patient.  However, the records fail to demonstrate the medical necessity of the requested epidurogram.  Final Result: The reviewer determined that a portion of the requested services is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned.  Credentials/Qualifications: The reviewer is board certified in physical medicine and rehabilitation 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.