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 CyberKnife treatment stereotactic body radiotherapy (SBRT). Findings:  The physician reviewer found that upon review of the available data, the use of SBRT for patients with very high risk prostate cancer is not supported. Outcome data for SBRT at this time is limited to five to six year follow up, and limited to patients with low risk or favorable intermediate risk disease. The most recent guidelines support the use of SBRT in treating low risk or favorable intermediate risk. However, studies on SBRT in higher risk groups are lacking. Thus, guidelines do not support the use of SBRT for patients who are considered very high risk due to seminal vesicle involvement on MRI. Therefore, in this patients case, CyberKnife treatment SBRT is not likely to be more effective than the available methods of treating this patients medical condition. Final Result: All three reviewers have determined 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 reviewers are board certified in radiation oncology and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested an electric powered wheelchair for the treatment of his medical condition.  Findings:  The physician reviewer found that the requested equipment has not been established as medically necessary for treatment of the patients medical condition. A power wheelchair has been requested to assist with mobility outside the home. Documentation indicates that a power wheelchair will allow improved community participation. Prior to consideration of a powered wheelchair, planning and evaluation is required to determine if he can safely use the equipment, and if it will be compatible with his abode and transportation methods. A plan for implementation of a powered wheelchair has not been documented. The patient is legally blind and must be able to safely use the device, have means of transport, and have an accessible abode. In addition, the patient has a personal mobility deficit that can be adequately addressed with a walker in the home environment. The patient is able to propel a manual wheelchair. Moreover, he will benefit from a walker with seat. The walker or manual wheelchair should meet his needs for community mobility. All told, the request for an electric powered wheelchair is not medically necessary for 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 physical medicine and rehabilitation with sub-specialty 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: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for 65 gram intravenous immunoglobulin (over eight hours) two times daily. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication. The patient is postulated to have an adult form of PANDAS.  Per the medical literature, the syndrome would be unlikely to occur in adults. The U.S. Food and Drug Administration approved indications for intravenous immunoglobulin do not include treatment of this syndrome. A randomized controlled trial by Williams and colleagues of immunoglobulin in children with this syndrome demonstrated no benefit from this therapy. In this patients case, there is a lack of evidence of a recent streptococcal infection. She has other diagnoses that explain her reported symptoms. All told, the requested 65 gram intravenous immunoglobulin (over eight hours) two times daily is not medically necessary 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 internal medicine with sub-specialty certification in infectious disease 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 56-year-old male enrollee has requested a yearly DEXA scan for evaluation of his hemiplegia and osteoporosis. Findings:  The physician reviewer found that the clinical evidence demonstrates the patient is on bisphosphonate, calcium and vitamin D therapy for presumed regional disuse osteoporosis. The Health Plans policy of approving scans every two years is reasonable in this clinical setting. There is no evidence that DEXA screening more often than every two years will show a significant change in bone mineral density. As such, there is no clinical indication for performing a DEXA scan on an annual basis.
Appeal type: Medical Necessity
Decision: Upheld

A 59-year-old female enrollee has requested transcranial magnetic stimulation therapy for treatment of her major depressive disorder. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  Transcranial magnetic stimulation is a non-invasive, neuro-stimulatory intervention endorsed by the American Psychiatric Association for the treatment of acute phase depression in the adult population.  A typical course of transcranial magnetic stimulation falls between 30 to 40 sessions.  There is a lack of adequately-powered, well-designed studies demonstrating the long-term clinical utility of transcranial magnetic stimulation maintenance therapy or its ability to prevent relapse.  In this patients case, she completed 35 transcranial magnetic stimulation treatments.  She had a positive response.  She was experiencing anticipatory anxiety with the transcranial magnetic stimulation tapering which came to fruition in her symptom report.  The extent of non-pharmacological, community-based interventions was not reported.  In sum, the medical evidence does not support continuing transcranial magnetic stimulation therapy, and the medical records indicate that standard therapies had not been exhausted.  Thus, transcranial magnetic stimulation from the date indicated forward was not and is not medically necessary for treatment of the enrollees medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: A enrollee has requested reimbursement for the Bioness L300 for treatment of the enrollee, who is status post arteriovenous malformation rupture. Findings:  The physician reviewer found that although a functional electrical stimulation is not indicated for all patients with hemorrhagic strokes and hemiparesis, there is medical literature supporting its use for a select population of patients. The literature has demonstrated the safety and efficacy of this device for patients with chronic upper motor neuron disease such as what occurs in foot drop induced by stroke. This patient has documented lower leg weakness secondary to the rupture of the arteriovenous malformation. In the past, she had a suboptimal response to an ankle foot orthosis.  Given that this patient had a suboptimal response to standard therapy, the Bioness L300 was likely to have been superior over other available treatment alternatives. Final Result: Two of the three reviewers determined that the device at issue was 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 reviewer number one is board certified in neurology 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.Physician reviewer number two is board certified in neurology 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.Physician reviewer number three is board certified in neurology 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 skilled nursing facility services from month-to-month and physical therapy services five times per week from month-to-month.The submitted documentation fails to demonstrate the medical necessity of the requested services. The patient has a history of chronic spinal cord injury. The primary goals of rehabilitation in this clinical setting are to maximize function, given the impairments. This patients lower limb strength is below the antigravity level. This is not a level of strength consistent with functional ambulation. He has been undergoing physical therapy at the skilled nursing facility but has remained at an essentially stable functional level of supervision for self-care, independence with wheelchair mobility, and nonfunctional short-distance ambulation. There is no medical necessity for further therapy services as he is at his functional baseline. Therefore, skilled nursing facility services from month-to-month and physical therapy services five times per week from month-to-month are not medically necessary for the treatment of this patient. 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 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: A female enrollee has requested authorization and coverage for anterior cervical discectomy/decompression and fusion (ACDF) surgery and two days of hospital stay for treatment of the enrollees cervical stenosis.  Findings:  The physician reviewer found that The request for ACDF surgery and two days of hospital stay have not been established as medically necessary for treatment of the patients medical condition. In this case, the patient presents with chronic neck pain. However, she has no symptoms or signs of a cervical radiculopathy or cervical myelopathy (Corey, et al). In addition, her physical examination was normal. There are no localizing features to her pain to implicate the C5-6 nor the C6-7 levels. Thus, her pain generator has not been identified. Moreover, there is no documentation that she has failed conservative management for six weeks. All told, the proposed surgery is not in accordance with the standard of care in this clinical setting. Accordingly, the requested surgery and related services are not medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the requested surgery and related services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Final Result: The reviewer determined that the requested surgery and related services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

A 65-year-old male enrollee has requested a wearable cardioverter defibrillator (LifeVest) for treatment of his medical condition.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the device at issue.  This patient presented with a recent myocardial infarction and a left ventricular ejection fraction of less than 35% while off medical therapy.  In this circumstance, there is potential for recovery of left ventricular function and there was no indication for immediate placement of a defibrillator, such as sustained or inducible ventricular tachycardia, syncope or aborted sudden cardiac arrest.  Placement of a prophylactic defibrillator is not recommended until a period of time greater than 40 days where continued left ventricular dysfunction is documented to persist in spite of appropriate treatment.  A prophylactic defibrillator before this time has not been demonstrated to improve outcome.  Studies assessing efficacy of prophylactic defibrillators early after diagnosis of myocardial infarction and reduced ejection fraction less than or equal to 35% before ventricular function has had a chance to recover have not demonstrated improved outcome.  The current medical evidence does not support the device at issue in this clinical setting.  All told, the wearable cardioverter defibrillator (LifeVest) from the time period specified was not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for Nutropin AQ Nuspin for treatment of the enrollees idiopathic short stature. Findings:  The physician reviewer found that The request for Nutropin AQ Nuspin is not medically necessary for treatment of the patients medical condition. The records support a diagnosis of idiopathic short stature, given the patients growth pattern and the normal growth factors. In October 2016, at the patients chronological age of six years and two months, the patients bone age was consistent with that of a five-year-old. The patients ongoing height velocity is consistent with children with short stature on the basis of constitution delay. The available laboratory data does not support a diagnosis of growth deficiency. As such, the patients growth pattern does not support GH therapy for this patient. Therefore, the requested medication has not been established as medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in pediatrics with sub-specialty certification in pediatric endocrinology 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 requested authorization and coverage of extracorporeal shock wave therapy (ESWT). The Health Plan denied the request indicating that the requested therapy is not medically necessary for treatment of the enrollees plantar fasciitis.One podiatry reviewer performed a medical necessity Independent Medical Review. The podiatry reviewer upheld the Health Plans denial on the basis that the requested therapy is not medically necessary.
Appeal type: Experimental/Investigational
Decision: Overturned

A 64-year-old female enrollee has requested for bilateral breast magnetic resonance imaging (MRI) for evaluation of her unilateral nipple retraction.  Findings:  Three physician reviewers found that a diagnosis may be difficult to confirm not only clinically but also by imaging criteria as often mammography and ultrasound may be negative in this type of tumor. It is true that MRI of the breast is associated with a high degree of false positive results, but if this exam is negative it would virtually rule out neoplasm. Thus, while the standard imaging studies are negative, the physical findings plus the family history mandate further investigation, and breast MRI would be the procedure of choice in this particular individual.
Appeal type: Medical Necessity
Decision: Overturned

A nineteen year-old male who has a history of recurrent keloids secondary to bilateral ear piercing is requesting authorization for surgery to remove the two keloids.  The patient underwent surgical excision of the keloids, unfortunately, painful keloids recurred.  Reviewers Findings:  The reviewing physician found that treatment of the patients keloids is medically necessary because of functional impairment secondary to pain.  The reviewing physician found that the Health Plan denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: A 63-year-old male enrollee has requested reimbursement and prospective authorization and coverage for residential treatment services for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found that the documentation submitted does not support the medically necessity of the services at issue in this clinical setting. The patients post acute withdrawal symptoms were not severe in nature. The records did not reflect that he had emotional, behavioral, cognitive, or impulsive symptoms that would have warranted this level of care.  The records noted that he was medically and psychiatrically stable. Moreover, his medication management and anti-craving medications could have been monitored in an ambulatory setting. The patient had a sponsor.  The records did not show evidence of a high degree of impulsivity, agitation, depression, mania, hallucinations, or any other significant symptom that would interfere with his care.  He was motivated and appeared to be working the program.  He and his wife were in family therapy.  He was cooperative and participating in his treatment plan.   Although he continued to struggle with his emotions and required further treatment to help develop coping skills, this did not require the structured environment of a residential setting. He could have been stepped down to an ambulatory level of care such as intensive outpatient program.  The patients records did not support or meet the clinical guidelines for residential level of care. For the reasons stated above, residential treatment services provided forward were not and are not medically necessary for treatment of this patient. Final Result: The reviewer determined that the services at issue were not and 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 psychiatry with sub-specialty certification in addiction psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Synvisc One injection for treatment of the enrollees knee pain.  Findings:  The physician reviewer found that there is sufficient support for the requested service in this clinical setting. Pagnano and Westrich conducted a systematic review on the efficacy and safety of repeat courses of hyaluronan therapy in patients with osteoarthritis of the knee and concluded that repeat courses of the hyaluronans were safe and effective in the treatment of pain associated with osteoarthritis of the knee. The current medical evidence supports hyaluronic acid injections to potentially delay total knee replacement for patients with pain that interferes with functional activities. Per the medical evidence, if there is documented significant improvement in symptoms for six months or more, and symptoms recur, it may be reasonable to do another series. There is no maximum amount of injections established by high-quality scientific evidence. This patient presents with a history of left knee osteoarthritis. She reported good results with a Synvisc One injection that lasted for approximately six months, with return of symptoms. Her prior conservative treatment has included physical therapy, rest, nonsteroidal anti-inflammatory drugs, bracing, and corticosteroid injections, with inadequate relief. Repeat viscosupplementation injections have been found to be safe and effective and allow for delay of knee replacement surgery. Given the previous response and to assist in delaying total knee replacement for this patient, repeat Synvisc One injection is indicated. Therefore, the requested Synvisc One injection 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 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.