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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for stem cell treatments for treatment of the enrollees cerebral palsy. Findings:  Three physician reviewers found that there is currently no U.S. Food and Drug Administration approved stem cell therapy for cerebral palsy. While there are some randomized trials that have been completed, most studies have a small sample size that is underpowered to detect statistical differences between groups. The evidence is largely limited by significant heterogeneity across these studies due to variation in the types of cerebral palsy and ages of participants that received intervention, the types of stem cells used, the types of transplant/transfusion methods used, the cell doses, the duration of treatment, the theoretical rationale for why the cells might offer a treatment effect, the type and intensity of concomitant rehabilitation, and the duration of follow up. Based on the available evidence, it is difficult to discern what would be the most effective stem cell therapy protocol and which cerebral palsy patients would best benefit from such therapy. The potential safety risks of stem cell therapy are numerous and not well documented among published studies. There is very limited evidence regarding the short term and long term safety of stem cell therapy for cerebral palsy, especially given the significant heterogeneity across studies in terms of the treatment used and treatment protocol. The paucity of evidence regarding the safety of stem cell therapy for cerebral palsy precludes drawing any conclusions about whether or not this treatment is safe for use among cerebral palsy patients. Final Result: Three reviewers determined that the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: All three physician reviewers are board certified in neurology 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 39-year-old male enrollee has requested Synvisc injections for treatment of his knee pain. Findings:  The physician reviewer found that viscosupplementation has been shown to be of value in the treatment of osteoarthritis. Viscosupplementation is most suitable for patients with mild to moderate arthritis, and in those patients for whom other modalities are contraindicated, or have failed, and as part of a comprehensive treatment strategy.  Additional study is needed to clarify uncertainties about the therapeutic effects of different products in various clinical situations, but management of osteoarthritis requires a combination of non-pharmacologic modalities, such as exercise and weight reduction, and pharmacologic modalities, including NSAID medications.  In this case, there is no documentation of any treatment other than the proposed viscosupplementation. There is no documentation of failure of other treatment, and no documentation of any contraindication, such as allergy. All told, in this patients case, the requested Synvisc injections are not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

A 60-year-old male enrollee has requested a power wheelchair or scooter for the treatment of his left lower extremity paralysis. Findings:  The physician reviewer found that multiple aids are available to a patient with mobility difficulty. Depending on the severity of the limitation, one type of assisted device may be more helpful than another. According to nationally accepted guidelines in this setting (Medicare), a power mobility device such as a power scooter may be appropriate for a patient with a personal mobility deficit that significantly impairs participation in mobility-related activities of daily living (such as toileting, feeding, dressing, grooming, and bathing) in customary locations within the home, provided the patient's condition is not ameliorable by a walker, cane or manual wheelchair. In addition, the patient must be able to safely operate the power mobility device. In this patients case, he is independent in all of the activities of daily living mentioned above despite having difficulty with walking. In addition, this patient does not use any assisted device such as a walker or cane. The evidence provided does not demonstrate that a power wheelchair or scooter is necessary for the patients activities of daily living. Furthermore, his condition, even his difficulties with walking for distances greater than 25 feet, would likely be ameliorated by use of a walker, cane, or a manual wheelchair.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The guardian of an enrollee has requested authorization and coverage for 40 hours per week of skilled nursing care services in the home (CPT code S9124). The submitted documentation supports the medical necessity of the requested services. In this case, home nursing is indicated to monitor vital signs, perform nursing assessment, provide gastrostomy tube care, monitor lungs sounds, assist with range of motion and monitor for skin breakdown. Common indications for private duty nursing often include the administration of medications, monitoring oxygen saturations, and enteral feeding, all of which are required in this case. Researchers evaluated specialist home-based nursing services for children with acute and chronic illnesses. The authors screened 4,226 titles, yielding seven randomized controlled trials with a total of 840 participants. Three studies reported a reduction in parental anxiety, and improvement in child behaviors was reported in three studies. Overall increased parental satisfaction was reported in three studies. Additionally, better parental coping and family functioning was reported in one study. While the family may be able to meet some of the ongoing needs of the patient in the short-term, this is not sustainable. Given the patients global developmental delays and ongoing need for gastrostomy tube care and oral suctioning, the requested services are medically indicated. Therefore, 40 hours per week of skilled nursing care services in the home (CPT code S9124) 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 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: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for magnetic resonance imaging (MRI) of the lumbar spine. The first appropriate imaging for the evaluation of low back pain with radicular symptoms is lumbar radiographs. According to the American College of Radiology, if the pain persists after four to six weeks of conservative management, and the patient is a surgical or intervention candidate, then MRI of the lumbar spine is the usually appropriate next examination. In this case, the records do not document four to six weeks of conservative management, which would include physical therapy, nonsteroidal anti-inflammatory drugs or exercise. There is documentation of a chiropractic visit in April 2018. The records document two physical therapy visits. The patient presented for physical therapy in June 2019. The initial plan was for six weeks of physical therapy. There is no documentation that this course of physical therapy was completed. At this time, MRI is not medically indicated. Therefore, the requested MRI of the lumbar spine is not medically necessary for the evaluation of this patient.   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.
Appeal type: Experimental/Investigational
Decision: Upheld

A 54-year-old male enrollee has requested a toe extension Dynasplint system for treatment of his status post hemi-implant arthroplasty of the right metatarsophalangeal joint.  Findings:  Three physician reviewers found that treatment for hallux limitus or hallux rigidus in the medical literature includes options such as footwear modifications, non-steroidals and surgery.  There is a lack of published high-grade medical literature supporting the efficacy of dynamic splinting using devices such as the Dynasplint in the setting of hallux limitus or hallux rigidus, whether preoperatively or postoperatively.  There is only very limited medical literature that is anecdotal in nature, such as case reports.  These case reports, moreover, were written by authors affiliated with the device manufacturer.  In the present case, the records forwarded for review do not establish that the patient gained significant benefit specifically from the Dynasplint intervention.  His range of motion gains followed the surgical correction.  No benefit in range of motion can be specifically apportioned to the Dynasplint.  Therefore, the toe extension Dynasplint system was not and is not likely to of greater benefit than other available treatment modalities.
Appeal type: Medical Necessity
Decision: Upheld

An enrollee has requested authorization and coverage for Otezla 30 mg tablet. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication in this clinical setting. The provider had checked off a box to indicate alcohol use by this patient, but a visit report noted a negative history for alcohol use. However, even with alcohol use and not abuse, the requested medication is not medically necessary. There are alternative treatments that are appropriate for this patient. The medical literature supports the use of methotrexate or ultraviolet light therapy in the management of patients diagnosed with plaque psoriasis. In this patients case, there is no documented adverse effect or contraindication to the use of methotrexate or ultraviolet light therapy. As such, the requested medication Otezla 30 mg tablet is not medically indicated for the treatment of this patient. 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 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: Overturned

The patient has requested authorization and coverage for upper and lower eyelift, cheek implants and upper lip lift. The records reviewed document that this patient has a history of gender dysphoria that has been improved with voice surgery and hormone therapy. The patient reports that her mood, breast development, and facial changes are more in line with her female identity. Her providers concur that the requested upper and lower eyelift, cheek implants and upper lip lift are indicated to address the patients gender dysphoria and associated distress. Facial feminization surgery is medically necessary for many transgender females to help alleviate the psychological distress they experience related to gender dysphoria. The World Professional Association for Transgender Health (WPATH) supports facial feminization surgery to help alleviate the distress associated with an incongruent physical appearance and gender identity. The WPATH has acknowledged that, For certain patients, an intervention like a reduction rhinoplasty can have a radical and permanent effect on their quality of life, and therefore is much more medically necessary than for somebody without gender dysphoria. The guidelines further report that, These reconstructive procedures are not optional in any meaningful sense but are understood to be medically necessary for the treatment of the diagnosed condition. Given this support, the upper and lower eyelift, cheek implants and upper lip lift are medically necessary for treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

A 26-year-old male enrollee has requested a NESS L300 Neuroprosthesis for the lower extremity and a NESS H200 Neuroprosthesis for the upper extremity for treatment of his spastic hemiplegia.  Findings:  Two physician reviewers found that overall, the clinical data from the scientific peer-reviewed literature is insufficient to establish the safety and efficacy of functional electrical stimulation devices for foot drop, including foot drop due to spastic hemiplegia. More significant research of a disinterested nature is needed to further evaluate the device manufacturers claims regarding these types of devices. Clinical trial of the device is currently ongoing to determine the effectiveness of the NESS L300 in improving gait parameters, function, and quality of life among stroke subjects with drop foot. This ongoing trial serves to underscore the fact that the efficacy of this device has not yet been established in the medical literature for the indication of foot drop due to neurological conditions.Furthermore, the evidence studying the NESS H200 Neuroprosthesis is even more limited. The studies to date are small case reports within stroke, multiple sclerosis, and spinal cord injury. The use of the NESS H200 device in traumatic brain injury has not not explored beyond these case reports. There is currently inadequate long-term (greater than two-years) outcome data from appropriately designed clinical trials showing the safety and efficacy of the NESS H200 device to support its use in this clinical situation.Based upon the information set forth above, the available literature does not present evidence that the requested functional electrical stimulation devices result in long-term functional change beyond standard of care modalities for either the upper or lower extremity.
Appeal type: Experimental/Investigational
Decision: Overturned

A 46-year-old female enrollee has requested for a double balloon enteroscopy for evaluation of her gastrointestinal bleeding.   Findings:  Three physician reviewers found that capsule endoscopy did show some small bowel ulcerations.  With double balloon enteroscopy, one is able to evaluate the ulcerations and cauterize them if necessary to treat the bleeding issue. Double balloon enteroscopy is medically appropriate for evaluation of this patient. It is likely to be more efficacious than alternative therapies.
Appeal type: Experimental/Investigational
Decision: Overturned

A 29-year-old male enrollee requested authorization and coverage of a Meniett-20 device. The Health Plan denied the request indicating that the requested equipment is considered investigational for treatment of the enrollees Menieres syndrome. Three physician reviewers performed an experimental/investigational Independent Medical Review. All three of the physician reviewers concluded that the requested therapy is likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy. Because all three physician reviewers concluded that the requested therapy is likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy, the Health Plans denial has been overturned.
Appeal type: Experimental/Investigational
Decision: Overturned

A female enrollee requested breast tomosynthesis (CPT code 77063) for medical evaluation of her medical condition. Findings:  Three physician reviewers found that there is sufficient support for the addition of digital breast tomosynthesis to routine mammography imaging.  Per the current medical evidence, the recall rate when using digital breast tomosynthesis is lower than when digital mammography is used alone.  The literature indicates that early breast cancer is detected with significantly increased frequency using the combination of digital breast tomosynthesis and digital mammography.  All told, breast tomosynthesis was likely to have been superior over other modalities for evaluating this patient.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Otezla.There is sufficient support for the requested medication in this clinical setting. Otezla has been demonstrated to be safe and efficacious for the treatment of psoriasis. The U.S. Food and Drug Administration (FDA) approved Otezla in 2014. Otezla (apremilast) is recommended for the treatment of moderate to severe psoriasis in adults. It receives an 'A' grade from the joint National Psoriasis/American Academy of Dermatology guidelines on the treatment of psoriasis. The guidelines of care do not state or show that treatment with a disease-modifying antirheumatic drug (DMARD), cyclosporine or soriatane is necessary or beneficial prior to treatment with Otezla. In this case, 10% of the patient has a body surface area is affected. Additionally, this patients treatment options are limited due to hypertension and his occupation. Therefore, Otezla is medically necessary for the treatment of the patients medical condition.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: Urgent Care
Decision: Overturned

A 50-year-old female enrollee has requested for emergency services for treatment of her abdominal pain.  Findings:  The physician reviewer found that the patients symptoms met prudent layperson criteria for emergency care. Based on the available medical records it appears that the patients pain had abruptly worsened that day. A prudent layperson with an average knowledge of medicine and acute onset of 6/10 abdominal pain would reasonably expect the absence of emergency care to jeopardize their health.
Appeal type: Medical Necessity
Decision: Upheld

A 42-year-old male enrollee requested to be admitted to a hospital for further testing and treatment of his chest pain.  Findings:  The physician reviewer found that in this clinical setting, cardiac evaluation has been exhaustive and negative for any ischemic coronary cause to the patients complaints. Likewise, additional evaluation has also been negative to assess for other life-threating causes of the patients ongoing chest symptoms. There are no documented symptoms or findings to warrant ongoing inpatient evaluation and treatment of the patients chronic chest discomfort. Based on the extensive and repeated negative evaluations performed, ongoing evaluation and treatment of the patients chronic chest pain can be safely continued as an outpatient at this time.  For the reasons provided, the requested services are not medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

A 54-year-old male enrollee requested authorization and coverage of intensity modulated radiotherapy for the treatment of prostate cancer. The health plan denied the enrollees request indicating that the requested treatment is experimental.Three physician reviewers performed an experimental/investigational Independent Medical Review.  Each of the three physician reviewers concluded that intensity modulated radiotherapy is likely to be more beneficial for treatment of the enrollees  prostate cancer than any available standard therapy.  Because all three physician reviewers concluded that the requested treatment is likely to be more beneficial for treatment of the enrollees medical condition than any available standard therapy, the review organization overturned the health plans denial.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 51-year-old male with a history of migraine headaches and epiphenomena consisting of olfactory hallucinations. His treating provider has recommended a second MRI of the brain. The patient had a previous MRI of the brain in June 2003 demonstrating a small, older lacuna infarct in the right basal ganglia (not the cause of either headaches or olfactory hallucinations), but otherwise normal. The Health Plan has denied authorization for the second MRI as not medically necessary. As set forth above, the patients initial MRI was otherwise normal except for an older lacuna infarct, which is not the cause of either the patients headaches or hallucinations. In the absence of previous findings or neurological signs and symptoms a second MRI is not medically indicated. This patient does not have focal neurological signs or symptoms. In addition, epiphenomena such as visual or olfactory hallucinations are commonly observed in patients with migraine headaches. Based upon this information, there is no indication that a second MRI is medically indicated. Therefore, I have determined the requested MRI is not medically necessary for evaluation 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 laser hair removal of excess growth of perianal hair.Findings:  The physician reviewer found that Hirsutism is a condition that refers to hair growth where hair does not normally grow. This condition is usually due to a malfunction of the pituitary gland in men or from certain medications. This patients record does not support the diagnosis of hirsutism. Perianal hair growth is normal and would not be worsened from previous shaving. The patient does not have an abnormal body part or an abnormally functioning body part. The medical studies indicate that shaving does not contribute to increase hair growth. As the patient does not have an abnormally functioning body part, any service to correct the problem would not be considered medically necessary. There is a lack of evidence in the body of literature to associate perianal hair growth to repeated hemorrhoid treatment. 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 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.