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

A 45-year-old female enrollee has requested a combination sit to stand system for treatment of her paralysis. Findings:  Two physician reviewers found that in this patients case, the requested equipment is appropriate. The patient has a spinal cord injury which prevents her from standing and is vulnerable to the subsequent consequences of not being able to stand such as pressure ulcers, contractures, decreased bone mineralization, and depression. Although the research literature does not conclusively substantiate the use of the standing frame for paralyzed individuals, there is compelling evidence of anecdotal responses from paralyzed patients as well as reports of overall improvement in psychological well being from the use of the standing frame. Given the potential negative effects of pressure ulcers, contractures, decreased bone mineralization, and depression in this patient population there is sufficient evidence to support the use of the requested combination sit to stand system in this patients case.  All told, the requested equipment is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for transcranial magnetic stimulation (TMS) provided and prospective authorization and coverage for future TMS services (two to three times per week). The Health Plan has denied this request indicating that the services at issue were not and are not medically necessary for treatment of the enrollees behavioral health conditions. The submitted documentation fails to demonstrate the medical necessity of the services at issue.  Researchers described a treatment protocol of five days per week, four to six weeks in duration.  Based upon the clinical documentation, the patient was unable to comply with five treatments per week due to mobility issues. The initial treatment period describes a total of eleven treatments, which is below the recommended frequency of treatments. Further treatments beyond this initial period do not have evidence based support as recommendations state that continuation of treatment is indicated in patients that complete a standard acute course of treatment. The protocol employed during the treatment period is not supported by current evidence.  Future TMS treatments that follow a treatment course of two to three times per week would not be supported by existing protocols due to the lack of an initial treatment course. Therefore, transcranial magnetic stimulation (TMS) provided and future TMS services (two to three times per week) were not and 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 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for the medication Dupixent Pen. Dupixent is FDA approved and supported in the medical literature as an add-on treatment of moderate to severe asthma in adults with an eosinophilic/allergic phenotype or with corticosteroid dependent asthma. In this case, the patient carries a diagnosis of asthma, which is an allergic phenotype based on an elevated IgE level. Records reflect that the patient's asthma has been poorly controlled, requiring two hospitalization and multiple rounds of systemic steroids in the recent past. Under these circumstances, Dupixent is appropriate for the management of the patients condition. Accordingly, the requested medication Dupixent  Pen is medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested medication is medically necessary to treat the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in internal medicine, with subspecialty certification in pulmonary diseases, 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:  The enrollee is requesting authorization and coverage for Femring Vag Ring 0.1 mg/24 hour with a quantity of two rings per 90 days. The enrollee is experiencing menopausal symptoms of hot flashes, post-menopausal bleeding and vaginal dryness.  She has tried and failed norethindrone, estradiol, and Estrace. Side effects from these medications caused a worsening of her symptoms. She is requesting approval for two rings as this therapy has provided symptom relief. Per enrollee report, the first fem ring alleviated some symptoms but a higher dosage was necessary.  As the fem ring is her only effective option, an additional fem ring is needed to supply the necessary dosage. Guidelines indicate the use of preparations such as the Femring include treatment of moderate to severe vasomotor symptoms and moderate to severe vulvar and vaginal atrophy due to menopause. Labeling information notes the Femring is available in two strengths; 0.05 mg/day, for a total of 12.4 mg of estradiol acetate, and 0.10 mg/day, for a total of 24.8 mg of estradiol acetate. The product is released at the specified daily dosage over three months. Femring has a black box warning about endometrial cancer, breast cancer and an increased risk of cardiovascular disease. This enrollee has a uterus and is therefore at risk for endometrial cancer. Higher doses of estrogen could possibly increase these risks.   There is no approval for the use of two rings. There is no data regarding the effectiveness, safety, side effects and long term risks of this product.Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in obstetrics and gynecology and reproductive endocrinology 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

Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting authorization and coverage for Continuous Positive Airway Pressure (CPAP). She has witnessed apnea, morning headaches and daytime somnolence.  She was referred to the sleep clinic for evaluation for obstructive sleep apnea (OSA). The sleep study report revealed mild OSA, with an apneahypopnea index (AHI) of 5.9. Respiratory events consisted of episodic clusters of obstructive apneas and hypopneas. Nadir oxygenation was 87.0 percent. Time spent with an oxygenation level of less than 90 percent was 0.9 minutes. Continuous positive airway pressure (CPAP) therapy was recommended at a follow-up visit. The therapy data summary noted the enrollee had an insufficient trial on auto CPAP therapy due to less than four hours of use. A repeat CPAP trial was recommended. Professional society guidelines note treatment of obstructive sleep apnea (OSA) with positive airway pressure (PAP) therapy should be based on a diagnosis of OSA; established using objective testing. The member meets this diagnosis based on her symptoms of witnessed apnea, morning headaches, and daytime sleepiness; scoring 11 out of 24 on the Epworth Sleepiness Scale, and having an unattended home sleep test using a portable respiratory sleep monitor that showed an apnea-hypopnea index of 5.9 per hour. Once the diagnosis of OSA is established, positive airway pressure therapy should be initiated, using either Automatic Positive Airway Pressure (APAP) at home or an in-laboratory PAP titration study, where this test would be used to demonstrate that PAP can treat the OSA as well as to determine what pressure settings are needed to achieve proper treatment.  The member had an at-home APAP study, but tolerated it for only one hour. The data obtained was inadequate data to determine efficacy. Therefore, CPAP is considered not medically necessary until there is data from a successful at-home or in-laboratory PAP titration study.Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in sleep 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 similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 69-year-old male enrollee has requested sensory integration therapy for the treatment of his status post stroke. Findings:  Three physician reviewers found that this patient suffered from a cerebrovascular accident with resultant speech and language problems. He was seen for speech therapy, which included Lessac-Madsen Resonant Voice Therapy. He was billed for standard speech therapy, as well as sensory integration therapy. However, based on the submitted therapy notes, the therapy given does not meet the sensory integration description. Even if the services included sensory integration therapy, such services were not likely to be more efficacious than standard speech therapy services in this setting. There is inadequate data in the peer-reviewed evidence demonstrating sensory integration therapy results in improved clinical outcomes in this patient population.
Appeal type: Medical Necessity
Decision: Upheld

A 40-year-old female enrollee requested authorization and coverage of a prosthetic water leg. The Health Plan denied the request indicating that the requested prosthesis 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 equipment is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 60-year-old female who has symptomatic large recurrent varicose veins on the left side. She is status post left side greater saphenous vein stripping. The photographs, history, and physicians findings confirm this. The patient has requested authorization and coverage for varicose vein surgery. The Health Plan has denied the request on the basis the requested surgery is not medically necessary. Review of the submitted documentation does not demonstrate the patients condition warrants surgical intervention at this time. There is no evidence the patient has undergone a recent trial of conservative treatment. If the patient fails to receive benefit from a trial of compression stockings, then her request for varicose vein surgery should be reconsidered. Accordingly, I have determined that the requested surgery is not medically necessary for treatment of the patients medical condition at this time. The Health Plans denial should be upheld at this time.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: A male enrollee has requested authorization and coverage for the medication, Stelara injection, 90mg/ml once, every four weeks. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees Crohns disease.Current medical literature supports dose escalation of Stelara in this case. A large randomized controlled trial demonstrated safety and efficacy for induction and maintenance of remission in patients with moderate-severe Crohn's disease that was resistant to anti-tumor necrosis factor therapy, which this patient has failed.   A study showed dosing at 90 mg every 4 weeks was used frequently to address inadequate disease control, and a large proportion of patients were able to maintain response with dose escalation to 90 mg every 4 weeks. Multiple other studies have shown that dosing intensification (to 90 mg every 4 weeks) was used frequently to address loss of response, and a large proportion of patients were able to maintain response. Additionally, in this case, alternative therapies are limited, several other conventional and biologic therapies for Crohns disease have failed. For these reasons, Stelara injection, 90mg/ml once, every four weeks is supported as medically necessary for the treatment of this patients Crohns disease.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 internal medicine with subspecialty certification in 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 a similar medical condition. Findings:  The physician reviewer found that
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 56-year-old female with an illness dating to mid 2001 manifested by numbness and tingling of the head, hands and feet. The patients providers notes indicate that she had EMG and nerve conduction studies, which suggested Guillain-Barre syndrome. The provider considered HSV, another neurological disease or an autoimmune illness. No documentation for any specific diagnosis has been submitted. The CDC criteria for chronic fatigue are not mentioned or demonstrated in the patients medical records. The patient is seeking authorization for Procrit.In September 2003, the patients red cell mass was 33% less than predicted and blood volume was approximately 15% less than predicted. The patients red cell count and hemoglobin have been normal.A search of medical literature reveals no evidence of any data to support the use of Procrit for this patient. The patient had normal hematological studies before she began treatment with this medication. After therapy began, the patients hematocrit began to approach a level at which there could be unwanted side effects from polycythemia. Based upon a lack of clinical and scientific evidence, there is no evidence to support authorization of the requested medication. Therefore, I have determined that the requested medication is not medically necessary for the treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for magnetic resonance imaging (MRI) for evaluation of right knee pain. Findings:  The physician reviewer found that In the medical literature, researchers noted in patients with knee pain, knowledge of the radiologic appearance of the abnormalities allows more accurate diagnosis of the cause of the pain including chondral abnormalities, patellar instability and dislocation, femoral trochlear dysplasia, abnormal patellar location, bipartite patella, various tendinopathies, bursal inflammation, traction apophysitis in pediatric and adolescent patients, and miscellaneous diseases including mediopatellar plica syndrome and Hoffas disease. The authors reported that MRI offers superior soft tissue contrast resolution and allows for more accurate evaluation of the underlying etiology and therefore may improve treatment and possible surgical planning. Other researchers reported that MRI is currently the modality of choice for detecting meniscal injuries and planning subsequent treatment. Thus, the literature does support the use of MRI to rule out other sources of intraarticular derangements, such as meniscal tear, for knee pain in this clinical setting. As this patients plain film x-rays have already excluded acute osseous fracture as a cause in this case, the requested MRI is supported as medically necessary for evaluation of this patients knee pain. Final Result: The reviewer determined that the requested diagnostic procedure is medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in diagnostic radiology 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 continued treatment by an infectious disease specialist who specializes in chronic fatigue syndrome. The submitted documentation fails to demonstrate the medical necessity of the requested services. The records document that this patient has been diagnosed with chronic fatigue syndrome. There are only a few clinics in the United States that concentrate on chronic fatigue syndrome, one of which is the clinic at Stanford. Most therapy used for patients who meet the diagnosis of chronic fatigue syndrome is unproven. Published studies do not provide evidence of clinical benefit from the antiviral treatment. There is a lack of published data that suggest better outcomes as a result of care at a clinic which specializes in chronic fatigue syndrome. Treatment is largely based on the patients symptoms. An infectious disease specialist who specializes in chronic fatigue syndrome is not necessary in order to effectively treat this patient. Therefore, continued treatment by an infectious disease specialist who specializes in chronic fatigue syndrome is not medically necessary in this patients case.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 internal medicine with sub-specialty certification in infectious 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: Overturned

This case involves a 52-year-old male with a right knee injury that occurred in February of 2005. He was diagnosed with an anterior cruciate ligament (ACL) tear at the time of the injury. The patient elected to forgo surgical reconstruction and has done well as long as he avoids activities where he would experience difficulty with the knee. At this point in time, the patient would like to resume some of his previous sporting activities. He and his orthopedist agree that a knee brace is needed to avoid reinjuring his knee. The patient has requested authorization for a Don Joy Defiance knee brace. The Health Plan has denied his request based upon a determination that the requested DME is not medically necessary.The June 2005 note from the patients orthopedist states the patient has instability with pivot/incline walking, a Grade II Lachman and a positive pivot shift. Although the December 2005 orthopedists note indicates there is no day-to-day instability, that observation should be considered in light of the patients activity limitations. He stated that he avoids walking on uneven ground and generally walks very carefully.  He no longer participates in sporting and recreational activities that would stress his knee joint. Furthermore, the patient does not want surgical reconstruction. As the patient does have a confirmed laxity with instability on pivot shift activities, a functional knee brace is medically necessary to prevent instability with more vigorous activities.  The L1886 or an L184 would meet the patients needs, however the additional polycentric knee joints, carbon graphite frame, or heavy knee joint included in the DonJoy Defiance knee brace are not medically necessary.Based upon the information set forth above, I have determined a portion of the requested DME is medically necessary for treatment of the patients medical condition. The Health Plans denial should be partially overturned.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Synvisc injections in both knees for treatment of the enrollees osteoarthritis in both knees. Findings:  The physician reviewer found that evidence based medical peer-reviewed literature supports the use of viscosupplementation injections for the treatment of pain in patients with osteoarthritis of the knee. Viscosupplementation has been found to be safe and effective and allows for delay of total knee replacement. Additionally, the literature indicates that viscosupplementation injections are more effective than corticosteroid injections. In this case, the patient has been diagnosed with osteoarthritis of both knees. He reported a history of knee pain and functional impairment in mobility that had failed to respond adequately to other conservative treatment, including steroid injections. Significant prior pain reduction and functional benefit was documented with viscosupplementation (in the form of Supartz). All told, Synvisc injections in both knees are medically necessary for the treatment of this patients medical condition.  Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.