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

An enrollee has requested reimbursement for septoplasty of the nose with replacement with grafts and ablation of the soft tissue of the inferior turbinates. The submitted documentation supports the medical necessity of the services at issue. The records documented deviated nasal septum and hypertrophic bilateral inferior turbinates. The patient had failed a trial of conservative therapy with nasal sprays to improve breathing through the nasal airway. The operative report indicated that the services at issue were performed to achieve a functional improvement in airflow. The medical evidence supports the services at issue in this clinical setting. Therefore, septoplasty of the nose with replacement with grafts and ablation of the soft tissue of the inferior turbinates were medically necessary for the treatment of this patient. In this case, the records document that the patients septum was significantly deviated and the turbinates were enlarged. This constitutes an abnormal structure of the body. The cause of the abnormal structure of the body was likely either developmental or a response to allergens. The services at issue were performed to improve function. Thus, septoplasty of the nose with replacement with grafts and ablation of the soft tissue of the inferior turbinates were reconstructive in nature. Final Result: The reviewer determined that the services at issue were medically necessary for treatment of the patients medical condition and were reconstructive in nature. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in plastic surgery with expertise in facial plastic and reconstructive 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 parent of an eight-year-old female enrollee has requested repeated esophageal dilation procedures within her local community, rather than at a facility that is approximately 130 miles/3 hours from her residence for treatment of the enrollees recessive dystrophic epidermolysis bullosa and recurrent esophageal stricture. Findings: The physician reviewer found that the submitted documentation demonstrates the medical necessity of the requested services. Epidermolysis bullosa represents a collection of disorders characterized by development of blisters with trauma and worsening in warm weather. This patient suffers from the recessive dystrophic type, involving severe blistering and scarring, including involvement of the gastrointestinal tract and urologic system. This is the most incapacitating of the disorders because of the mucous membrane involvement and impact on nutrition and growth. Flexion contractures and cutaneous carcinomas may eventually develop, requiring removal and tissue release. Special skin grafts and bone marrow transplantation may offer relieve in some cases. This patient has failed stem cell transplantation. The health plan has referred the enrollee to another facility because their local institutions are not equipped to deal with the care that she requires. While the facility in question has a well-respected and recognized clinic that specializes in epidermolysis bullosa, the commute is 3-4 hours each way. Obstruction due to esophageal structure is a semi-emergent situation requiring rapid dilation for relief. In addition, due to the severity of her disease, such a long drive is intolerable and may exacerbate her condition. She has been involved with a pediatric gastroenterologist locally that understands the intricacies of her care. It is medically necessary to provide this patient local treatment with a subspecialist that knows her well. Therefore, it is medically necessary and appropriate for this patient to continue to receive esophageal dilation procedures within her community.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/ Case Summary:  The enrollee requested coverage for intensive outpatient services and partial hospitalization program services. The enrollee has a history of eating disorder symptoms and a diagnosis of anorexia nervosa. The enrollee was at high risk of relapse and further decompensation with discharge to an outpatient treatment program. Although her weight was healthy, she needed assistance to continue to monitor her deficits, mood, impulse regulation, self-esteem and behavior problems.  Findings:  The physician reviewer found that the medical literature supports the use of intensive outpatient therapy for this enrollee.  According to the  medical literature, services for treating eating disorders can range from intensive inpatient programs (in which general medical care is readily available) to residential and partial hospitalization programs to varying levels of outpatient care. Final Result: The reviewer determined that the requested services were medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in Psychiatry and AddictionPsychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The parent of an 11-year-old male enrollee has requested  for resumption of Nutropin growth hormone therapy for treatment of the enrollees Prader-Willi syndrome and short stature. Findings:  The physician reviewer found that growth hormone therapy for treatment of short stature associated with Prader-Willi syndrome was approved by the FDA in 1995 and has been shown to be efficacious and safe for continuous long-term administration in these children, as noted by De Lind Van Wijngaarden and colleagues. Impaired growth hormone secretion in patients with Prader-Willi syndrome contributes to abnormal body composition and energy expenditure and abnormal carbohydrate and lipid metabolism.  Administration of growth hormone therapy has not only been shown to improve linear growth, but also promotes growth of lean body mass, decreases fat mass by increasing fat oxidation and total body energy expenditure, and improves cardiovascular risk factors.  Patients with Prader-Willi syndrome do not necessarily have classic growth deficiency, yet have been shown to benefit from growth hormone therapy. Thus, the fact that this patient did not undergo growth hormone provocative stimulation tests and that his bone age is normal should not be taken as evidence that growth hormone therapy is not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for vertical sleeve gastrectomy. Findings:  The physician reviewer found that the records noted a body mass index (BMI) of 40.04 kg/m2. The patient had lost six pounds in preparation for surgery. The records included a comprehensive multidisciplinary evaluation that did not reveal any obvious dietary or behavioral concerns. Given that patients should be evaluated at their starting weight and not penalized for optimizing with preoperative weight loss in preparation for metabolic and bariatric surgery, this patient met the criteria for bariatric surgery based on her initial BMI. The requested service is medically indicated. Therefore, a vertical sleeve gastrectomy is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested service 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 general 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

A 62-year-old female enrollee has requested home health physical therapy (PT) for the treatment of her gait instability and poor balance. Findings:  The physician reviewer found that it is not clear as to why this patient was unable to be managed in an outpatient program. Based on the nurse evaluation the patient is mostly independent with activities of daily living and can ambulate with a cane or walker at minimum distances. There is no evidence that the patient is homebound.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Orthovisc injections in the left knee and authorization and coverage for a requested Orthovisc injection series in both knees.Current medical literature pertaining to viscosupplemention reveals mixed results. Evidence from eight systematic reviews and six randomized controlled trials indicates that although viscosupplementation may relieve knee pain in some individuals with chondromalacia and osteoarthritis, it is not known as to which individuals will benefit. Different studies have tried mixing hyaluronic acid with corticosteroids, platelet rich plasma, and other agents to make it more effective. The current evidence is limited, and guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate that the evidence is not conclusive. As such, the academy does not currently support viscosupplementation as standard treatment for osteoarthritis of the knees. In light of the foregoing, viscosupplementation can only be recommended in individuals with a history of lasting benefit from prior injections, and in carefully selected cases where everything else has been tried and the options are limited. In this case, there is documentation of chondromalacia of patella of both knees. Conservative treatment including physical therapy, platelet rich plasma injections, and cortisone injections have been tried without success. Under these circumstances, the Orthovisc injections in the left knee were medically necessary to treat the patients medical condition. In addition, the requested Orthovisc injection series in both knees is medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the services at issue and requested services were, and are, medically necessary to treat the patients medical condition. Therefore, the Health Plans denials 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: An enrollee has requested authorization and coverage for custom foot orthotics. Findings:  The physician reviewer found that Pes planus, by its nature, does not always cause pain. Further, Banwell and colleagues state, No high level evidence supports the use of foot orthoses for flexible pes planus. In this case, the patient has been diagnosed with congenital pes planus and strain of unspecified muscle and tendon at ankle and foot level. According to the medical literature, the use of orthoses is not supported in patients with pes planus alone. Moreover, the diagnosis of strain of unspecified muscle and tendon at the ankle and foot level right foot does not necessitate orthotic treatment.  In order to establish the medical necessity of the requested equipment, a more extensive physical examination and a more definitive diagnosis are needed. Therefore, the requested custom foot orthotics are not medically necessary for the treatment of the patients medical condition.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 podiatry 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: A 55-year-old female enrollee has requested authorization and coverage for methadone 10 mg, Vicodin 10 mg, Norco 325 mg, and hydrocodone for treatment of the enrollees degenerative disc disease, bilateral knee joint pain, and lumbar facet arthropathy. Fulfills Findings:  The physician reviewer found that the step wise World Health Organization (WHO) ladder for pain relief is considered the reasonable approach to pain control in the palliative and the non-palliative settings. The Centers for Disease Control and Prevention (CDC) also state when opioids are started, providers should prescribe the lowest effective dosage. Providers should use caution when prescribing opioids at any dosage, carefully reassess evidence of individual benefits and risks when considering increasing dosage of 50 or more morphine milligram equivalents (MME) per day, and should avoid increasing dosage to 90 or more MME per day. In this case, the patient was recently taking well over 90 MME per day. However, in the documentation provided for review, no objective treatment goals for pain and function are noted for the requested medication and several requirements for opioid prescribing have not been documented. Further, dose escalation is a short-term, not long-term plan. Increases in the past appear to have been done only on the basis of the patients pain levels and not all other non-pharmacological methods such as behavior therapy of treating the patients pain have been addressed. Finally, the current taper plan is reasonable and there is a lack of documentation supporting these medications to alter the current taper plan. For these reasons, the request for authorization and coverage for methadone 10 mg, Vicodin 10 mg, Norco 325 mg, and hydrocodone, are not medically necessary for treatment of the patients medical condition.  Final Result: The reviewer determined that the requested medications 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 anesthesiology 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: Upheld

A 59-year-old male enrollee has requested sinus surgery (CPT code 31287, nasal/sinus endoscopy, surgical with sphenoidotomy, 31254, nasal/sinus endoscopy, surgical, with ethmoidectomy, partial, and 31256, nasal/sinus endoscopy, surgical, with maxillary antrostomy) for treatment of his pneumosinus dilatans. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services in this patients case.  The records provided do not clearly document the frequency of sinus infections.  The CT scan showed a very mild amount of scattered mucous membrane thickening within the paranasal sinuses which could have been the effect of a common cold or other viral syndrome.  Although the patient does have dilation of some of the paranasal sinuses, there is a lack of evidence indicating that endoscopic sinus surgery is indicated to treat dilation of the paranasal sinuses.  Although the patient was found on physical examination to have deviation of nasal septum, the CT evidence suggests that the deviation is mild.  Additionally, the submitted clinical notes do not suggest any restriction of airflow or any obstruction of nasal airflow.  The current medical evidence does not support the requested services in this clinical setting.  All told, the requested sinus surgery is not medically indicated in this patients case.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the stereotactic body radiotherapy (SBRT) performed for treatment of the enrollees prostate cancer. Findings:  Two physician reviewers found that there is a lack of long-term studies supporting the use of SBRT for the treatment of prostate cancer. The literature review concluded that Studies of SBRT provide encouraging results of biochemical control and late toxicity. However, they are limited by a number of factors, including short follow-up, exclusion of intermediate- and high-risk patients, and relatively small number of patients treated. Currently, SBRT regimens should only be used in the context of clinical trials. Moreover, SBRT is not well-established in the literature for high risk disease. Thus, the SBRT performed was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: The reviewers determined that the services at issue were 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 radiation 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: Urgent Care
Decision: Overturned

The parent of a 3-year-old female enrollee has requested emergency services for treatment of the enrollee's medical condition.  Findings:  The physician reviewer found that the issue in this case is whether a prudent person in the patients circumstances would believe he or she was experiencing an emergent medical condition requiring emergency medical services. An emergent medical condition means a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in any of the following: placing the patients health in serious jeopardy, serious impairment to bodily function, or serious dysfunction of any bodily organ or part. With regard to this patient, she presented with what was probably H1N1 flu for which she was already taking the anti-viral antibiotic, Tamiflu. Her temperature in the clinic was 103.5 degrees and in the ED, 2 days later, it was even higher at 103.6 degrees. At that time, a new diagnosis of a bacterial infection was made, specifically otitis media, which required the prescription of an anti-bacterial antibiotic in addition to the anti-viral antibiotic that the patient was already taking for the flu. The acute onset of a bacterial infection such as otitis media combined with a high fever that was actually increasing constituted a valid emergent condition for which the parent was reasonable in seeking immediate medical assistance.
Appeal type: Medical Necessity
Decision: Overturned

A 41-year-old female enrollee requested authorization and coverage of the medication Provigil. The Health Plan denied the request indicating that the requested medication is not medically necessary for treatment of the enrollees bipolar disorder.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plans denial on the basis that the requested medication is medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Acthar Gel.Acthar is FDA approved for treatment of proteinuria associated with nephrotic syndrome. There are numerous published case reports (series) of clinical response to Acthar in IgA nephropathy. Zand and colleagues conducted a prospective open-label pilot study and concluded that patients with IgA nephropathy with proteinuria >1 g/24-hour and estimated glomerular filtration rate (eGFR) >30 ml/min had a significant reduction in 24-hour urinary protein with stable eGFR at 12-month follow-up after being treated with 6 months of Acthar Gel. Prasad and colleagues also conducted a study that concluded that Acthar is an effective agent that is well tolerated with minimal side effects and can be used as an alternative to prednisone in patients with IgA nephropathy. In this case, the patient has proteinuria and IgA nephropathy that has proven refractory to conventional therapy. Under these circumstances, the requested Acthar Gel is medically necessary to treat 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 internal medicine, with subspecialty certification in nephrology, 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

This patient is a 46-year-old female with an apparent history of depression who has been treated with Serzone for several years. Her provider indicates the medication is essential in her treatment despite the consistently reported side effects of fatigue and hypersomnia. The patients provider notes a positive response to a trial of Provigil and has requested authorization for the medication. The Health Plan denied the request citing a lack of medical necessity.The FDA-approved indications for Provigil do not include the treatment of idiopathic hypersomnolence or hypersomnolence as a side effect of another medication. The use of Provigil to offset the sedating effects of the patients Serzone may encourage polypharmacy and is not a generally recommended approach. Although the patients provider indicates that Sezone is essential to the patients treatment, there is no objective evidence of a trial of other antidepressants that may be less sedating than Serzone. Therefore, I have determined the requested medication is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.