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

An enrollee has requested authorization and coverage for laparoscopic anti-reflux surgery utilizing LINX. Findings:  The physician reviewer found that the U.S. Food and Drug Administration (FDA) has approved the LINX Reflux Management System for lower esophageal sphincter augmentation. Eligible patients for the procedure include those with inadequate symptom control with maximal acid suppression therapy, mild to moderate GERD, and a hiatal hernia less than 3 cm. This patient meets these criteria. Finally, five-year cohort data was recently published establishing the durability of the device. In a group of 85 patients, augmentation of the lower esophageal sphincter with a magnetic device provided significant and sustained control of reflux, with minimal side effects or complications. All told, this patient meets the specific criteria for treatment with the LINX system. Thus, the requested laparoscopic anti-reflux surgery utilizing LINX is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: The reviewers determined that the requested procedure is 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: the physician reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology 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: Experimental/Investigational
Decision: Upheld

A 41-year-old female enrollee has requested localized hyperthermia with low dose radiation treatment for treatment of her breast cancer. Findings:  Three physician reviewers found that this patient is requesting low dose radiation for the treatment of an early stage breast cancer. Per the submitted documentation, it appears as if the patient has decided to avoid standard oncologic care. The use of hyperthermia with radiation is limited to chest wall recurrences and metastatic disease. It is not meant to replace standard treatment, including surgery, radiation therapy, chemotherapy and hormonal therapy when indicated. Current National Comprehensive Cancer Network guidelines do not support the requested services in this clinical scenario. Thus, the requested localized hyperthermia with low dose radiation treatment is not likely to be the most efficacious treatment alternative for this patient.
Appeal type: Experimental/Investigational
Decision: Overturned

A 31-year-old male enrollee has requested a smart pill (wireless capsule motility test) for evaluation of his gastrointestinal issues. Findings:  Two physician reviewers found the submitted documentation and relevant literature supports the use of a smart pill (wireless capsule motility test) in this clinical setting. A review of the medical records shows that the patient has developed severe abdominal pain and decreased ability to evacuate his bowels with prior subtotal colectomy for colonic inertia. Thus, a small bowel motility disorder is probable, and it is important to make this diagnosis as it will affect therapy as well as provide prognosis. Moreover, the requested service is approved by the U.S. Food and Drug Administration for the evaluation of gastric emptying time in patients with suspected gastroparesis, the evaluation of colonic transit time in patients with suspected chronic constipation, and for the characterization of pressure profiles from the antrum and duodenum (Tran et al). Thus, the requested smart pill (wireless capsule motility test) is likely to be more beneficial than other modalities and is appropriate for the evaluation of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for Stelara. The U.S. Food and Drug Administration (FDA) approves the use of Stelara for the treatment of moderate to severe plaque psoriasis in adults and pediatric patients. Menter and colleagues note that guidelines on the management and treatment of psoriasis do not include step therapy. In this case, given that the provider recommends treatment with Stelara based on the patients clinical history, the requested medication is medically indicated. Therefore, Stelara is medically necessary to prevent disease, disability, and other health conditions or their progression.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 dermatology 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 monthly intravenous immune globulin (IVIG) therapy for treatment of the enrollees multiple sclerosis (MS). Findings:  The physician reviewer found that the documentation does not detail all the various medications the patient has tried and failed or what was considered drug failure. In addition, the records do not indicate focal neurologic findings, imaging findings, or tests in support of progression of disease while on current therapy. Further, IVIG is not U.S. Food and Drug Administration (FDA) approved for treatment of MS and the current peer-reviewed publications do not support IVIG as a routine therapy for MS. Melzer and Meuth noted that MS and chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) represent chronic, autoimmune demyelinating disorders of the central and peripheral nervous system that share some fundamental pathogenic elements. However, the authors noted that treatments do not provide uniform effects across both disorders. 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 physician reviewer is board certified in neurology 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 parent of a seven-year-old male enrollee has requested speech therapy twice per week for treatment of the enrollees autism.  Findings:  The physician reviewer found that the American Academy of Neurology (AAN) and Child Neurology Society (CNS) evidence-based guidelines for autism recommend speech therapy for autistic children. Specifically, the guidelines state that the goal of early identification of speech and language problems is to initiate early intervention, which has been shown to improve outcomes for children who have autism spectrum disorder. In the case of this patient, he has benefitted from speech therapy with weekly progress notes showing progress toward goals. In addition, new goals have been set for the patients ongoing deficits. Given that speech therapy is standard of care for patients with autism and in light of the patients documented deficits, speech therapy twice a week is medically necessary for treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

A 48-year-old male enrollee has requested a cardiac specialist referral for treatment of his family history of heart murmurs.  Findings:  The physician reviewer found that based on the records provided, this patient presents with a family history of unspecified heart murmurs but no documented cardiac symptoms. In addition, he has a normal cardiovascular physical exam without any cardiac murmur recorded. In this circumstance of a clinically stable patient without cardiac symptoms and with a normal cardiovascular physical exam without murmurs, referral to a cardiologist is not considered standard accepted practice in the medical community. Current guidelines endorsed by several national organizations do not recommend cardiology evaluation with echocardiography in patients without cardiac symptoms and without cardiac murmurs on physical exam (Douglas, et al). Moreover, there is no documentation of a family history of specific cardiac conditions that may be genetic and associated with a murmur such as hypertrophic cardiomyopathy or rarely bicuspid aortic valve and atrial septal defect (Gersh, et al). All told, the requested cardiology referral is not medically necessary for treatment of this patients medical condition based on the documentation provided for review.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 12-year-old female enrollee has requested residential treatment center services (RTC) for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found the records indicate that the RTC services were medically necessary for treatment of this patients medical condition. According to the documentation submitted for review, this patient meets the criteria for residential level of care. Treatment during the last week prior to discharge was appropriate in order to help consolidate treatment gains and allow her to successfully step down to intensive outpatient program (IOP) without risk of a relapse and readmission. It is documented in the records that the patient was extremely anxious and depressed about her upcoming discharge, and she was very fearful of being triggered into a relapse. Given her mothers unstable state at family therapy on the date indicated, only a few days prior to discharge, it was likely that her family was not ready to provide the support she would require after discharge. Thus, without the RTC services, it is likely that she would have quickly relapsed and required readmission. Therefore, based on the medical literature cited above and the documentation submitted for review, the services at issue were medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 66-year-old male who is diabetic and has a non-healing foot wound.  The providers notes are difficult to read, but it is apparent that the wound is deep and beefy red and there is no indication of infection.  The pedal pulses are not palpable and it is not known if they can be assessed with Doppler. No ankle-brachial index or toe pressure measurements were apparent in the medical record provided for review.  The patient has requested authorization for treatment of his foot wound with Regranex 0.01% gel. The Health Plan denied his request based upon a determination that the therapy is not medically necessary.The manufacturer of Regranex lists the indications for its use as the treatment of lower extremity diabetic neuropathic ulcers that extend into the subcutaneous tissue or beyond and have an adequate blood supply.  An adequate blood supply is important in order for the growth factors in Regranex to be effective, and studies showing the clinical benefits of treatment with Regranex required that the wound have an adequate blood supply. In this instance, the provider documents that the patients pedal pulses are not palpable.  This could be an indication that the patients blood supply is not adequate for wound healing. Objective physiologic tests such as the ankle-brachial index and toe pressure measurements that would provide confirmation of the adequacy of the blood supply are not included in the record. As such, it appears that the blood supply is inadequate and the use of Regranex would be considered off-label.  While off-label usage does not preclude medical necessity, a specific justification for such use should be provided.  In this setting neither the adequacy of the blood supply nor a special circumstance justifying the use of Regranex have been established.Based upon the information set forth above, I have determined the requested therapy is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a 15-year-old male enrollee has requested direct applied behavioral analysis (ABA) therapy and supervision for treatment of the enrollees autism spectrum disorder. Findings:  The physician reviewer found that although ABA therapy has been documented in multiple studies to significantly improve motor, verbal, and social interactive skills in the early intervention stage, the medical and psychological literature is not conclusive regarding the number of hours or the duration of therapy, or the individual characteristics of a patient who will respond to ABA therapy. The appropriate duration and frequency of ABA therapy must be determined on an individual basis with consideration of the patients previous response to therapy. In this case, the patient presents with markedly maladaptive social skills and a limited ability to communicate. The medical records do not clarify when ABA therapy was initiated or the total years of ABA therapy the patient has received, however according to the records submitted for review he has had ABA therapy with the same provider. During this period, his multiple projected goals have not resulted in significant functional improvement. Although the school reports no behavioral issues, he continues to experience inappropriate behaviors at home and exhibits destructive outbursts. This suggests that he has had a minimal response to ABA therapy at/near the requested frequency, as does recent psychometric testing which indicated the patient was functioning at an age indicated. All told, ABA therapy is medically reasonable and appropriate in this particular setting. Accordingly, the requested services are not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for facial laser hair removal. The Health Plan has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees gender dysphoria and are not reconstructive in nature. Findings: Facial hair removal is clinically appropriate for treatment of gender dysphoria. The record notes that hormone therapy has not been effective in treating this patients excessive facial hair. Therefore, facial laser hair removal is medically necessary for treatment of this patients gender dysphoria.With regards to whether the requested services are considered reconstructive in nature, excessive facial hair in a female is considered an abnormal body structure. It would be abnormal for a female to have terminal hair on the face. The patients abnormal appearance is the result of gender dysphoria, a disease classified as a disorder. Facial laser hair removal can provide a substantial improvement in the appearance of terminal hair and create a normal appearance to the extent possible. Facial laser hair removal would also provide more than a minimal improvement in the appearance of this patient. For these reasons, facial laser hair removal is reconstructive in nature. 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 dermatology 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 41-year-old female enrollee requested authorization and coverage of plantar fascia release and bone spur removal for the treatment of plantar fasciitis and heel spur.  The Health Plan denied the enrollees request indicating that the requested treatment 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 surgery is not medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

An enrollee has requested authorization and coverage for Xeljanz. In the treatment of alopecia areata, current medical literature shows that the higher the percentage of involvement, the more aggressive the treatment. Strazzulla and colleagues note that a published algorithm recommends topical and oral steroids with minoxidil, sensitization, Janus kinase (JAK) inhibitors, or prostheses in cases with 50% or greater scalp involvement. For cases with less than 50% scalp involvement, the algorithm recommends immunotherapy. In this case, visit notes reported that the patient was completely devoid of scalp, facial, and body hair, and had not responded to typical therapies. In this clinical setting, current medical literature supports the use of JAK inhibitors to treat the patients condition systemically. Therefore, Xeljanz is likely to be more beneficial for treatment of the patients condition than any available standard therapy.Findings:  Three of the three physician reviewers found the requested Xeljanz is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested medication is 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: 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

Findings:  The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for RT300 neuromuscular functional electrical stimulation (NMES) therapy device (E1399). The RT300 NMES provides passive range of motion in patients with neurological weakness by using topical electrical stimulation leads to activate paralyzed limb muscles to drive a stationary cycle. Current data have not demonstrated that use of the RT300 NMES improves function or health outcomes in a clinically significant manner for patients with spinal cord pathology (Hofer and Schwab). The RT300 NMES device has not been shown to improve cardiovascular health, pulmonary health, or other health parameters to support its routine use (Ralston, et al.; Nardone, et al.; Soleyman-Jahi, et al.; Phadke, et al.; Farrow, et al.). The current guidelines and the medical literature does not include use of an NMES as part of the functional rehabilitation of patients with spinal cord injuries. The health and well-being in this patient population should be promoted with active exercise using volitionally intact arm muscles and active participation in educational, social, and recreational activities at a wheelchair level (Tweedy, et al.). All told, the requested RT300 NMES therapy device (E1399) is not medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested equipment is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in 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: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for ultrasound and magnetic resonance imaging (MRI)for evaluation of the enrollee who recently had an abnormal mammogram study. Findings:  The physician reviewer found that while breast MRI has an important role in both screening and diagnostic settings, the documentation submitted does not support the medical necessity of the requested services in this clinical setting. In the last several years, the American Cancer Society (ACS) and the American College of Radiology (ACR), have established guidelines for the appropriate use of breast MRI. As per the ACS/ACR guidelines, those screening indications include screening for the high risk patient, screening the contralateral breast in a patient with a recently diagnosed breast malignancy, and screening in patients with breast augmentation. In this patients case, she does not meet the criteria for being at high risk for developing breast cancer as defined by ACR/ACS guidelines. Overall, MRI studies of the breast are highly sensitive but have a relatively low level of specificity. The medical literature does not recommend the use of breast MRI as a replacement for routine breast mammography and ultrasound. It is common for an MRI report to state that there are subtle abnormalities that are not indicative of definite tumor and a follow-up MRI is recommended. When there is a clearly defined mass, sonography is excellent in distinguishing a cystic from a solid lesion, but in the clinical setting of suspicious calcifications, a negative or a positive sonogram will not change the need to do a biopsy. The ACR has established appropriateness criteria for the evaluation of breast lesions, and they are clear that If suspicious calcifications are present in the mass, biopsy is indicated regardless of stability or margination. Though a mass was not detected in this patient, the new development of calcifications is enough to warrant a biopsy. Final Result: The reviewer determined that the requested services are not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld. 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.