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

A 47-year-old female enrollee has requested skilled nursing care and rehabilitation services for treatment of her diabetes type II open chest wound.  Findings: The physician reviewer found that negative pressure wound therapy (NPWT) has improved the patients wound to the extent that there is significant granulation tissue with no signs of infection. She was noted to have improving health, tolerating therapy, and having good glycemic control along with nutrition. Although there is concern of the patients living environment, this would be of equal concern if her wound was healed. Living conditions can be arranged and addressed through social services support. Wound dressings are commonly applied at home by home health nursing agencies including NPWT dressings, and this level of care can help address the patients safety issues at home. Extended use of NPWT can lead to fistulas as well and a topical dressing can be used at home for appropriate wound closure (Simek, et al). It is considered the standard of care to manage sternal wounds in the outpatient and home health setting (Damiani, et al). Although poor glycemic control can place a patient at risk of wound infections, her sugars were noted the month specified(Kramer, et al). Based on the information provided, there is no additional indication that her wound cannot be managed outside of a SNF setting. Any concerns of her home status does not relate to her wound since this would need to be addressed regardless of any wound care. All told, the services provided at the SNF level of care from the date indicated and forward are not supported as medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 50-year-old female with a history since October 2003 of visual distortion in the left eye. She has a past medical history of irregular vaginal bleeding with normocytic anemia (history of normal endometrial biopsy); hepatitis C; and back pain. The patient also reports a history of migraine headaches. The patients optometrist indicated the patient needed to see a retinal specialist after seeing a distortion on the membrane of the retina. The patient was seen by an ophthalmologist who noted the patient had 20/20 vision in both eyes. In November 2003, a Humphrey visual field test showed non-specific changes, and fundus exam/photos and fluorescein angiogram revealed a splinter heme in the left eye. It appears a follow-up appointment was scheduled but was subsequently canceled. The patient continues to experience distorted vision and headaches, and reports that she has difficulty driving and reading. She has requested authorization for a referral to a retinal specialist. The Health Plan has denied the patients request on the basis that a referral to a retinal specialist is not medically necessary.The submitted documentation does not demonstrate the requested referral is medically necessary. A general ophthalmologist is capable of evaluating the retina and rendering an opinion as to whether follow-up or referral is necessary. The submitted evidence shows the patients ophthalmologist has chosen to continue follow-up with the patient. A referral to a retinal specialist may be necessary in the future based on the results of the follow-up examination; however, at this point there is no medical indication for the requested referral. Therefore, I have determined that the requested referral is not medically necessary for the 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 authorization and coverage for temazepam 30 mg. The American Academy of Sleep Medicine (AASM) clinical practice guidelines for chronic insomnia note that there is weak evidence to support the effectiveness of temazepam as a treatment for sleep onset and sleep maintenance insomnia (Sateia, et al). Further, the AASM assert that cognitive behavioral therapy for insomnia (CBT-I), is a standard treatment with a reassuring safety profile. The guidelines further indicate that medications for chronic insomnia disorder should be considered mainly in patients who are unable to participate in CBT-I, who still have symptoms despite participation in such treatments, or, in select cases, as a temporary adjunct to CBT-I. This patients records do not document an adequate trial of CBT-I. In sum, based on current practice guidelines, the requested temazepam 30 mg is not supported as medically necessary for treatment of this patients medical 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 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

The patient has requested authorization and coverage for Euflexxa injections for both knees, once a week for three weeks. Review of the current medical literature pertaining to viscosupplementation reveals mixed results. Although viscosupplementation may relieve knee pain in some patients with osteoarthritis, it is unknown which patients will benefit. Considering the foregoing, viscosupplementation can only be recommended for patients with a history of lasting benefit from prior injections and in carefully selected cases when everything else has been tried and the options are limited. In this case, the patient has a history of a good result from prior viscosupplementation injections. Furthermore, the patients options are limited. The patient has tried and failed other conservative treatments, with the alternative being bilateral total knee arthroplasties. The medical evidence supports the requested services in this clinical setting. Therefore, Euflexxa injections for both knees, once a week for three weeks are medically necessary for the treatment of this patient. 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.
Appeal type: Medical Necessity
Decision: Overturned

A 55-year-old female enrollee requested removal of a cyst for medical treatment of the 2 cm cyst on her anterior chest wall.  Findings:  The physician reviewer found that excision and closure can be very difficult with inflamed cysts, and it may be preferable to postpone the surgical procedure until the inflammation has subsided to operate on a non-inflamed cyst (Zuber). The standard of care for this case is to surgically remove the cyst while it is not inflamed in order to avoid complications. This patient has an enlarging epidermal inclusion cyst that can get inflamed and rupture. This could lead to infection and even antibiotic-resistant bacteria leading to sepsis. Consistent with these findings, removal of the cyst as requested by this patient is supported as medically necessary and reconstructive in nature for treatment of her medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a five-year-old female enrollee has requested a tonsillectomy and adenoidectomy for treatment of the enrollee, who has a history of recurring tonsillitis and adenoiditis, sore throat and upper airway resistance.Findings:  The physician reviewer found that in this patients case, surgical intervention may improve not only the symptoms of recurrent acute pharyngitis and tonsillitis, but also significantly improve symptoms of sleep disordered breathing.  The medical references document that not all children require polysomnogram prior to consideration of surgical intervention. The medical literature notes that children with recurrent acute pharyngitis have a better outcome following surgery.  This patient is somewhat overweight and may have a moderate degree of obstructive sleep apnea which was not adequately recorded on the polysomnogram.  However, there was a significant increase of upper airway resistance. Surgical intervention to improve the upper airway resistance and the oropharyngeal obstruction is recommended in this clinical situation. Thus, the requested surgical services are medically indicated for this patient.
Appeal type: Medical Necessity
Decision: Overturned

A 45-year-old female requested authorization and coverage of the medication Lamisil for the treatment of onychomycosis.  The health plan denied the enrollees request indicating that the requested medication is not medically necessary.One podiatry reviewer performed a medical necessity Independent Medical Review.  The podiatry reviewer overturned the health plans denial on the basis that the requested medication is medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a wheelchair accessory power standing system. Findings:  Two physician reviewers found that as discussed in the current peer-reviewed medical literature, there is a paucity of consistent high quality studies demonstrating improved patient outcomes with use of standing frames. Further studies are needed to adequately evaluate the potential benefits of standing devices. Although the device is reported to provide positive effects in terms of spasticity, pain, and improved bone metabolism, the studies performed were limited in sample size and lack long-term follow-up. Furthermore, existing bone mineral density loss and osteoporosis might cause fractures in patients who stand prematurely and without a well-designed progressive standing program. The documentation provided for review reveals that this patient has osteoporosis, scoliosis, and contractures, all of which are noted to be precautions and/or possible contraindications to a standing device. Additionally, there is no indication that she has undergone assessment to determine her current standing tolerance. These precautions and the possibility of fracture or inability to tolerate the requesting standing device may make the patient more susceptible to falls. All told, the requested wheelchair accessory power standing system is not likely to be more beneficial for treatment of this patients medical condition than any available standard therapy. Final Result: Two of the three reviewers determined that the requested equipment is 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:  One reviewer is board certified in physical medicine and rehabilitation and is actively practicing. One Reviewer is board certified in physical medicine and rehabilitation and is actively practicing.  One Reviewer is board certified in neurology with subspecialty certification in neuromuscular medicine and is actively practicing.  All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

A 22-year-old female enrollee has requested Botox injections for treatment of her temporomandibular pain and headaches.  Findings:  Two physician reviewers found that the medical records indicate that the primary reason this patient was treated with Botox has been migraine headaches. While Botox is experimental for the treatment of TMJ dysfunction, it is FDA approved for the treatment of migraines. In the scientific data, Diener and colleagues reported on large studies evaluating the safety and efficacy of Botox for migraine. The authors found numerous studies with positive outcomes capable of reproduction outside of the research environment. This patient has been treated with multiple medications and narcotics including methadone. The records document that the frequency of visits to her provider and need for pain medications were decreased when treated with Botox. Given this patients response to Botox therapy, the treatment should be approved for her migraines. With regard to frequency of treatment, Botox should not be administered more than every 3 months as the results last approximately 3-4 months.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a 16-year-old female enrollee requested intensive outpatient program services for treatment of the enrollees eating disorder.   Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  The patient had no suicidal, homicidal, or psychotic ideation.  She was not a danger to herself or others.  The patient was medically stable and she was managed on Prozac.  She participated in her treatment and meal plans.  The patient showed significant improvement as evidenced by the reduction in her eating disorder behaviors.  She had steadily gained weight and was at 105% of her ideal body weight.   Her treatment plan did not require frequent modifications or contact with staff requiring this intensive level of care.  The current medical evidence does not support the requested services in this clinical setting.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:   An enrollee has requested Harvoni for treatment of his hepatitis C virus (HCV). Two physician reviewers found that according to the American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) guidelines, Successful hepatitis C treatment results in sustained virologic response (SVR), which is tantamount to virologic cure, and as such, is expected to benefit nearly all chronically infected persons. Evidence clearly supports treatment in all HCV-infected persons, except those with limited life expectancy (less than 12 months) due to non-liver-related comorbid conditions. In addition, the AASLD/IDSA guidelines state that High priority for treatment owing to high risk for complications include patients with fibrosis (Metavir F2). This patient has a Metavir of F2. Hence, treatment is indicated immediately. Moreover, guidelines support the use of Harvoni for treatment-naive patients with HCV genotype 1a infection. As such, the patients request for Harvoni is medically necessary.  Final Result: Two reviewers 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:   One reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. Two reviewers are board certified in gastroenterology and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent an enrollee has requested authorization and coverage for 20 hours per week of direct applied behavioral analysis (ABA) therapy and 12 hours per month of supervision for treatment of the enrollees autism. Findings:  The physician reviewer found that the peer-reviewed literature has not definitively established how much ABA is necessary for children with autism. The study by Sallows and Graupner found that intensive behavioral treatment for children with autism was effective. In this case, the patient is in his sixth year of ABA treatment. However, he continues to have maladaptive behaviors. The research suggests that the patient can tolerate a reduction in his ABA hours. Final Result: The reviewer determined that a portion of the requested services are 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 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for photodynamic therapy (CPT 96567 and J7308) provided on 12/19/17. The Health Plan has denied this request indicating that the services at issue were considered investigational for treatment of the enrollees actinic keratosis.Findings:  PDT is an effective therapy for AK that consists of topical application of a photosensitizer followed by exposure of the treatment area to a visible wavelength light source.  It is a U.S. Food and Drug Administration (FDA) approved therapy for AK of the scalp and face. The patient in this case has tried and failed several other standard therapies and so it was medically appropriate to use PDT for treatment of his skin pre-cancers. Multiple trials and meta-analyses have compared PDT with other therapies for AK. One meta-analysis of four randomized trials (641 participants with 2170 AKs) comparing PDT with cryotherapy found that PDT had a 14% greater likelihood of achieving complete lesion clearance at three months than cryotherapy (Patel et al). The appropriate treatment is generally chosen based on the number of lesions present and the efficacy of the treatment.  While destructive therapy with liquid nitrogen is standard, the FDA has approved five therapies for the treatment of actinic keratoses. These are topical 5-fluorouracil (5-FU), 5% and 3.75% imiquimod cream, topical diclofenac gel, ingenol mebutate, and PDT with topical delta-aminolevulinic acid. The provider noted failure with multiple standard therapies. All told, PDT (CPT 96567 and J7308) provided on 12/19/17 was likely to have been a superior treatment option for treating this patients AK than the available standard therapies. Final Result: All three reviewers determined the services at issue were likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications:  All three reviewers are board certified in dermotology and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for genetic testing performed on 9/30/16.Findings:  The physician reviewers found that the patient was diagnosed with invasive ductal carcinoma of her breast in September 2016. Her family history includes a sister who was diagnosed with breast cancer at age 51 and a sister who was diagnosed with pancreatic cancer at age 47. Three paternal aunts were also diagnosed with breast cancer and one paternal aunt was diagnosed with ovarian cancer (all are deceased). On the basis of her personal history of breast cancer and significant family history of cancer, the patients treating provider recommended a genetic panel test. The patient is requesting reimbursement for the genetic tests performed on 9/30/16. The Health Plan denied the services at issue as investigational for the evaluation of this patient. The medical evidence supports the efficacy of a portion of the services at issue.  This patient has a personal history of breast cancer as well as a significant family history of cancer. She meets the criteria outlined and recommended by National Comprehensive Cancer Network Guidelines (NCCN) guidelines and the US Preventative Services Task Force for BRCA genetic testing. However, the testing performed on 9/30/16 was a 25 gene panel that included BRCA within it but also a variety of other suspected risk genes. Although many of these other gene mutations are of real interest and are being studied, they have not been found to be significant enough to be the basis for clinical decisions for the carriers or their family members. Such broad testing is not included within guidelines from major organizations. Final Result: Two reviewers determined that a portion of the services at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be partially overturned. Credentials/Qualifications: All three physician reviewers are board certified in internal medicine with sub-specialty certification in medical oncology 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 22-year-old male enrollee has requested speech therapy for the treatment of his dysfluency. Findings:  The physician reviewer found that stuttering is generally diagnosed as language skills develop in children.  In 80% of cases, this is thought to be a developmental problem, although the exact underlying cause is not completely understood. Spontaneous remission is noted approximately 70% of the time.  As noted in the study by Block and colleagues, although some short-term efficacy has been seen in adults who receive additional behavioral and speech therapy, relapse in the long-term is common. There is insufficient evidence that any immediate gains will be maintained over an extended period. Given that the long-term efficacy of speech therapy in adult patients with this condition has not been demonstrated, speech therapy is not medically indicated for this patient.
Appeal type: Medical Necessity
Decision: Overturned

The parent of an 11-year-old female enrollee has requested growth hormone therapy (Genotropin) for the treatment of the enrollees growth failure. Findings:  The physician reviewer found that the requested growth hormone therapy is medically necessary for this patient in this case. Her familial and idiopathic short stature is such that she is destined to become a short adult (less than 4 feet 11 inches) without growth hormone therapy (Genotropin). In addition, she is under the appropriate care of a supervising endocrinologist, and other causes for her poor growth have been excluded.