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

Nature of Statutory Criteria/Case Summary: An enrollee has requested spinal stenosis surgery for treatment of his medical condition. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested services.  The medical literature recommended surgery for spinal stenosis for patients who do not improve with conservative treatment.  The current peer-reviewed literature supports spinal stenosis surgery in this clinical setting.  This patient presents with evidence of severe stenosis and radiculopathy.  Detailed evidence of a recent, comprehensive non-operative treatment protocol trial and failure has been submitted.  All told, spinal stenosis surgery is medically indicated 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: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for knee scooter. The documentation indicates that the patient was recently evaluated and has no change in her neurovascular status. The patient was advised to weight bear as tolerated. The provider reports that the patient is ambulatory with crutches, which does not suggest that the patient requires a knee scooter for mobility. There is no medical indication on examination or imaging that prohibits weightbearing as recommended by her providers. The providers recent office notes document complaints of back pain with burning and tingling at the ankle up the back of the leg. These symptoms are not likely consistent with her ankle injury alone and may be suggestive of a possible alternate etiology that would not be alleviated with a knee scooter. The current medical literature reports concern regarding the higher incidence of falls associated with knee scooters. For these reasons, the requested knee scooter is not medically necessary for this patient. Final Result: The reviewer determined that the requested device 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 with subspecialty certification in neuromuscular medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 61-year-old female enrollee has requested platelet rich plasma injections for treatment of her medical condition. Findings:  Three physician reviewers found that the requested services are not likely to be more effective than other available treatment options.  The current medical evidence has not established the superior efficacy of the requested services in this clinical setting.  Cerciello and colleagues noted that while reports regarding the use of platelet rich plasma injections in in-vitro models are promising, further research is needed to establish the efficacy of platelet rich plasma injections and to adopt standardized protocols.  Additional studies are needed to demonstrate the overall efficacy and safety of platelet rich plasma injections versus standard therapy.  Thus, the requested platelet rich plasma injections are not likely to be of greater benefit than other treatment alternatives.
Appeal type: Medical Necessity
Decision: Overturned

A 46-year-old female enrollee has requested breast reduction surgery for treatment of her macromastia.  Findings:  The physician reviewer found that the submitted documentation and relevant literature demonstrates the medical necessity of the requested procedure. In this case, the patients large breasts hang down touching her pants which constitutes an abnormal structure of the body caused by a developmental abnormality. The surgery proposed would create a normal appearance to the extent possible. It would also likely improve function as breasts that large likely interfere with function. The breast reduction surgery offers more than a minimal improvement in the appearance of the patient. All told, based on the medical records submitted for review and the peer-reviewed literature, the requested procedure is medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 10-year-old male enrollee has requested for 20 hours per week of direct ABA therapy (code H2019), 10 hours per week of parent training (code H0046) and 12 hours per month of supervision (code H0032) for treatment of the enrollees autism.  Findings:  The physician reviewer found that the medical literature strongly supports the use of ABA therapy in young children with autism. ABA therapy has been documented in multiple studies to significantly improve motor, verbal, and social interactive skills in young autistic children. However, there is limited scientific literature regarding the efficacy of ABA therapy as applied to older children or teenagers. The appropriateness of continuing ABA therapy in such patients depends upon the patients prior response to treatment as well as the likelihood of further benefit.In the case of this patient, he has had six years of intensive ABA therapy; despite this intensive therapy his present full-scale IQ is 46. The patient continues to present with poor attention/concentration skills, which has impaired his progress. While substantial gains are not likely, continuation of ABA therapy is medically appropriate in this setting to increase the patients social and peer related experiences. An article by Reichow and Volmar concluded that social skills can be improved by ABA therapy in older children Therefore, it is medically necessary that the patient continue to receive 10 hours per week of direct ABA therapy, 1 hour per week of parental training and 2 hours per month of supervision.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a 13-year-old female enrollee has requested acute inpatient psychiatric level of care services for treatment of the enrollees mood disorder and anxiety.  Findings:  The physician reviewer found that modern psychiatric practice aims to place patients in the least restrictive treatment setting possible to optimize treatment gains. Episodic placement in more restrictive settings is at times clinically appropriate. Applying clinical guidelines and patient placement criteria, this patients distress and recent history support the initial acute admission. The patient was plagued by a recurrent depressive symptom complex with anxiety, self-injurious behavior and suicidality. However, the record does not support the continuation of acute level of care services as of the date indicated. From the time of admission, she had consistently denied suicidal ideation. The patient was not psychotic, delusional or cognitively impaired. On the date indicated, the provider described the patient as calm, interactive with peers, and having no issues with sleep. On a subsequent date, her thought process was linear, coherent, and goal-directed. She was adherent with her medication and had a supportive family. All told, treatment in a less restrictive treatment setting would have been safe, appropriate and reasonably expected to improve the patients condition. Consistent with the American Psychiatric Association (APA) guidelines and the relevant peer-reviewed medical literature, the acute inpatient psychiatric level of care services provided from the date indicated and forward is not supported as medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for the brand name drug Zoloft. According to the U.S. Food and Drug Administration (FDA), a generic drug is created to be the same as an existing brand name drug in dosage, form, safety, effectiveness, strength, stability, and quality, as well as in the way is taken and should be used. In this case, there is a lack of documentation of failure or intolerance to the generic form of Zoloft. Thus, the requested brand name drug Zoloft is not supported as medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the requested brand name 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for genetic testing for factor II (prothrombin) and factor V Leiden mutation. Findings:  Three physician reviewers found that surgery is a known risk factor for deep venous thrombosis. Clinical guidelines for heritable thrombophilia testing and management were published in 2010 based on review of available evidence in the medical literature. The summary recommendation of these guidelines is that testing for heritable thrombophilias is not indicated in unselected patients presenting with venous thromboembolism. The results of testing do not help guide clinical management, nor do they help predict risk of recurrence. There is insufficient evidence to assess whether genetic testing influences patient management or clinical outcomes. The clinical utility of genetic testing in patients with a provoking risk factor, such as surgery or immobilization, would be expected to be even less than in those with an unprovoked venous thromboembolism. In sum, genetic testing for factor II (prothrombin) and factor V Leiden mutation was not likely to have been of greater benefit than other methods of evaluating this patient.Final Result: The 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 reviewer 1 is board certified in clinical biochemical genetics and is actively practicing. Physician reviewer 2 is board certified in clinical genetics and genomics and is actively practicing. Physician reviewer 3 is board certified in clinical cytogenetics and genomics and is 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 74-year-old female enrollee has requested for Vertos minimally invasive lumbar decompression (MILD) procedure for treatment of her spinal stenosis.  Findings:  The physician reviewer found that review of the available scientific data on the procedure, one peer reviewed article evaluating this procedure from Deer and colleagues is a retrospective review of only 90 patients. Another study from Chopko and Caraway is also a small study of only 75 patients that lasted 18 months. In addition, both studies are flawed in that neither had controls or were randomized. Thus, there are no large, scientific, randomized, long-term studies that have established the safety and effectiveness of the MILD procedure. Further, there are alternative treatment options available to this patient proven to be effective.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for total left knee replacement with the Mako Robot (MAKOplasty).Findings: Three out of three physician reviewers found that the requested total left knee replacement with the Mako Robot is not likely to have been more beneficial for the enrollee than any available standard therapy.The current standard of care for total knee replacement is with the use of traditional instrumentation and techniques. Excellent long-term functional and patient reported outcomes have resulted with these methods as substantiated in many high-level published reports. Short-term and medium-term follow-up studies of robotic-assisted total knee replacement have shown slight improvements over traditional methods in terms of component alignment, but this has not yet translated to improved functional and patient reported outcomes. Given the current absence of robotic long-term outcomes, superiority over traditional total knee replacement has not yet been established. Therefore, total left knee replacement with the Mako Robot is not likely to be more beneficial for treatment of the patients condition than any available standard therapy.Final Result: The reviewers determined that the requested service is not likely to have been more beneficial than any available standard method of evaluation for the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewers 1, 2, and 3 are board certified in orthopedic surgery and is 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

The patient is a 26-year-old woman who has requested myofascial release therapy for the treatment of vulvodynia. The submitted records indicate the patient experiences vulvar and rectal burning, itching, vaginal pain with penetration, burning with urination, and vaginal discharge. The patient has been receiving myofascial release therapy from an out-of-network provider. The patients treatment regimen also consists of connective tissue manipulation, muscle energy techniques, and neuromuscular re-education. The patient has requested authorization for continued therapy. The Health Plan has denied her request indicating that there is insufficient evidence to support myofascial release technique for vulvodynia. Myofascial release therapy is not standard of care for treatment of vulvodynia. Review of the current medical literature does not reveal any peer-reviewed case controlled studies evaluating the effectiveness of myofascial release therapy for this indication. Thus, there is no evidence demonstrating that the requested therapy is medically indicated. The physical therapy services offered by the Health Plan are more clinically appropriate. Therefore, I have determined that 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

A 55-year-old male enrollee has requested a computerized tomography (CT) of the pelvis for an evaluation of his abdominal and chest pain. Findings:  The physician reviewer found that this patient has no documented symptoms pertaining to the pelvis region. On physical exam, no abnormalities are noted that relate to the pelvic area. There are no other imaging studies that show an abnormality of the pelvic region. Therefore, there is no medical evidence to support a CT scan of the pelvis for this patient at this time.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 48-year-old male with onychomycosis confirmed by a April 2006 fungal culture which was positive for alternaria species. His symptoms include crumbling and deterioration of the toenails. Liver function tests from June 2006 were within normal limits. The request for authorization of Lamisil from the enrollees provider was denied by the Health Plan based upon a determination that the medication is not medically necessary.Loss of one or more toenails is a medically significant functional impairment. The toenails serve a protective purpose for the toes and feet and generally decrease the risk of infection. Additionally, the loss of a toenail is often painful. The patients dermatologist has proposed treatment with the oral medication Lamisil. This is a medically appropriate treatment approach as topical agents are minimally effective at best. Therefore, I have determined the requested medication is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a two-year-old female enrollee has requested authorization and coverage for speech therapy, at a frequency of two times per week, for one hour per session for treatment of the enrollees delayed expressive language skills.  Findings:  The physician reviewer found that the submitted documentation demonstrates the medical necessity of the requested therapy in this patients case.  As noted by Nelson and colleagues, speech and language development is considered by experts to be a useful indicator of a childs overall development and cognitive ability and is related to school success.  The authors noted that identification of children at risk for developmental delay or related problems may lead to intervention services and family assistance at a young age when chances for improvement are best.  Speech and language delay must be taken seriously in young children, because the long-term consequences may be substantial.  According to Law and colleagues, approximately 6% of children have speech and language difficulties.  The authors noted that children whose difficulties persist into primary school may have long-term problems concerning literacy, socialization, behavior, and school attainment.  These reviewers concluded that there is a positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulties.  In a recent review of therapeutic intervention for children with speech and language delay, McLaughlin noted that there are good data available to support the effectiveness of speech and language therapy, particularly for children with primary expressive language disorder.  This patient demonstrates expressive language delay, and this is negatively impacting her ability to communicate in a functional and age-appropriate manner.  Studies have shown that speech and language therapy can result in significant improvement in this clinical setting.  All told, speech therapy, at a frequency of two times per week, for one hour per session, is medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

A 25-year-old female enrollee has requested an increase in Enbrel dosage to 75 mg/ml per week for the treatment of her rheumatoid arthritis. Findings:  The physician reviewer found that the clinical trials of etanercept showed that a dose of 100 mg/ml weekly was not more efficacious than 50 mg/ml weekly in the treatment of rheumatoid arthritis as discussed by Johnson and colleagues. There does not appear to be any support in the literature for a dose of 75 mg/ml weekly. Thus, there is insufficient evidence to justify increasing the dose of Enbrel above the manufacturers recommended dose. Alternative treatments such as a steroid taper could be considered and would be consistent with the standard of care in this setting.
Appeal type: Experimental/Investigational
Decision: Overturned

A 52-year-old female enrollee has requested selective internal radiation therapy (SIRT) for the treatment of her colon cancer. Findings:  Three physician reviewers found that the current National Comprehensive Cancer Network (NCCN) Guidelines for Colon Cancer include criteria for resectability of metastasis and local regional therapies. These guidelines indicate that ablative techniques (such as SIRT) may be considered alone or in conjunction with resection. In addition, the medical literature shows a significant response of hepatic metastases to SIRT treatment. The use of SIRT in this case is medically reasonable and is consistent with national guidelines.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for durable medical equipment (DME)  powered upper extremity range of motion assist device, elbow, wrist, hand, finger, single or double upright(s), custom. The proposed DME is not expected to practically assist this patient in performing any self-care tasks requiring dexterous upper extremity use such as feeding, grooming, dressing, or bathing. The DME does not have the responsiveness or degrees of freedom to assist in these types of tasks in a practical, meaningful, and efficient manner. In addition, this patient has a weak left shoulder, which makes it difficult for him maneuver the left upper extremity, with the weight of the brace added to it, into positions where he can use the brace effectively for the purposes of self-care. Moreover, the requested DME has not been demonstrated to help patients regain neurological or muscular strength or function, such that the patients ability to use the arm for functional tasks is improved when the orthosis is removed. The DME has not been shown to improve health or outcomes following a stroke, such as reducing the incidence of overuse injury of the unaffected limb. There are also safety concerns related to the use of this device, which is heavy and can cause the shoulder to sublux. This can be mitigated with the use of a chest harness, but the need to wear a harness will further reduce the likelihood of adoption of the device in a community setting. The DME may also cause a patient with hemiparesis to have greater difficulties with gait due displacements in the patients center of gravity with use of the device. Given these findings, the requested DME  powered upper extremity range of motion assist device, elbow, wrist, hand, finger, single or double upright(s), custom is not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested device 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.