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

Nature of Statutory Criteria/Case Summary: An enrollee has requested enrollee has requested authorization and coverage for implantation of the hypoglossal nerve stimulator. Findings:  The physician reviewer found that the documentation provided does not support the superior efficacy of the requested services in this patients case. Specifically, the records do not indicate that this patient has exhausted other methods of management. Other surgical procedures have not been attempted such as improvement of the nasal airway with turbinate reduction and possible nasal septal reconstruction. These methods have not been shown to improve sleep apnea but can improve tolerance to nasal CPAP therapy, which is the gold standard modality for treating OSA. Additionally, the patient may be a candidate for other traditional oropharyngeal surgery such as uvulo-palatopharyngoplasty with tonsillectomy, which has been effective in improving symptoms. As such, while the requested implantation with a hypoglossal nerve stimulator have shown some efficacy in treatment of OSA, the research has not shown that it is superior to the available standard options. Accordingly, in this patients case, implantation with a hypoglossal nerve stimulator is not likely to be of greater benefit than the available standard procedures for the treatment of this patients medical condition. Final Result: All three reviewers determined that 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 reviewers are board certified in otolaryngology 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

A 56-year-old male enrollee requested authorization and coverage of esophagogastrectomy and colon interposition. The Health Plan denied the request indicating that the requested procedure is not medically necessary for treatment of the enrollees esophageal cancer.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested procedure is not medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld

A 52-year-old female enrollee has requested high intensity ultrasound using magnetic resonance imaging (MRI) guidance for treatment of her uterine fibroids and menorrhagia. Findings:  Three physician reviewers found that the FDA approved the use of this modality in the treatment of uterine fibroids following the completion of a multicenter trial. One study concluded that high intensity ultrasound using MRI guidance demonstrated promise for a non-invasive method of fibroid treatment but cautioned that a randomized clinical trial was necessary to confirm whether this treatment has a role in the available treatment options for fibroids. In addition, there are no adequate peer-reviewed studies directly comparing the efficacy and safety of this treatment with available standard alternatives. Although initial results are promising, the long-term results are currently unknown. Consistent with these findings, the services at issue were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested radiofrequency neurolysis for treatment of his sacroiliitis and lumbosacral spondylosis without myelopathy.  Two physician reviewers found that radiofrequency neurolysis is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. According to the documentation submitted for review, the patient is fused at L3-4 and L5-S1. The provider recommended a radiofrequency at L5-S3. The peer reviewed literature does not support radiofrequency ablation at levels that are already fused. The medical literature does provide evidence for the utility of sacroiliac joint rhizotomy for pain due to lumbosacral degenerative disc disease. However, the procedure is not likely to be beneficial in patients who have had spinal fusion where the medial and lateral branch nerves are disrupted. Given the provider has requested radiofrequency neurolysis at a level that is already fused, the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result:  Two 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: One reviewer is board certified in anesthesiology with sub-specialty certification in pain medicine and is actively practicing.  Two reviewers are board certified in anesthesiology and pain medicine 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: Overturned

The patient is a 21-year-old male admitted to residential treatment after an overdose of alcohol, cocaine, and methamphetamine superimposed on a long-standing history of such drug usage, which began on a daily basis at age 17. After an initial period of 18 months worth of abstinence following an outpatient treatment program at age 18, he subsequently relapsed using prescription opiates, cocaine, methamphetamine and alcohol. By the point of referral to residential treatment, he demonstrated an impaired ability to execute daily tasks such as personal grooming, responsibility, and adherence to a daily schedule. He also lacked a recognition regarding the severity of his chemical dependency and demonstrated characteristics of an undiagnosed bipolar disorder. He remained in residential treatment from January 2006 through March 2006.During treatment he was seen in formal psychiatric consultation, diagnosed with bipolar disorder, and begun on Depakote, titrated up to 500mg twice daily and from which he was felt to have benefited.The issue at hand is whether residential treatment beyond January 2006 was medically necessary for treatment of the patients condition.Based upon the submitted progress notes, it appears that the patient was fairly hypomanic, at the least, much beyond January 2006 and though he was felt to have improved from the prescribed Depakote, he was still seen as easily agitated in groups through March 2006. As such, he was noted as agitated and irrational, and was discharged with a relapse potential rated as moderate. Given that his bipolar disorder was not only problematic in and of itself, but would also predispose him to recurrent substance abuse, there are grounds to consider him in need of continued residential treatment beyond January 2006. Clearly, ending residential treatment with an evaluation of agitated and irrational does not speak to a particularly stable position, and therefore the patient was not suitable for transfer to a lesser level of care at that time. Accordingly, I have determined the services at issue were medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

A 39-year-old female enrollee has requested a power-operated vehicle (POV) for her mobility. Findings:  The physician reviewer found that there is no description of the patients actual motor strength in terms of a 0-5 point scale submitted, nor is there documentation of the patients actual walking distance, her ability to ambulate in the home, or of any specific inability to perform activities of daily living within the home. There is no objective clinical evidence demonstrating that the patient cannot functionally ambulate within her home.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for wireless capsule endoscopy. Findings:  The physician reviewers found that this patient has colonoscopy and biopsy findings suggestive of possible Crohns disease. Capsule endoscopy is useful for the diagnosis of Crohns disease or determination of the extent of disease activity, and superior to radiographic imaging tests such as small bowel follow through. Capsule endoscopy has been proven to be superior to all current forms of radiological testing of the small intestine in detecting the mucosal abnormalities of non-stricturing Crohns disease. Moreover, the test is supported by guidelines for the diagnosis of Crohns disease. For these reasons, requested wireless capsule endoscopy is likely to be more efficacious than the available standard therapy for the treatment of this patients medical condition.  Final Result: Two of the three reviewers determined that the requested wireless capsule endoscopy is likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications:  One reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. One Reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing.  One Reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is 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: The patients parent has requested reimbursement for cranial remolding orthosis.Findings:  The physician reviewer found that Positional plagiocephaly and deformational brachycephaly are terms used to encompass abnormal head shape due to a wide variety of etiologies and can range from mild to severe. Patients with mild and moderate plagiocephaly or brachycephaly may respond to mechanical adjustments and exercises. However, some patients present with severe and refractory to repositioning. The current treatment for patients with mild head shape abnormalities includes repositioning, physical therapy, and increased time in the prone position. Most providers currently recommend cranial orthoses for infant patients with moderate to severe skull deformities. The American Association of Neurological Surgeons (AANS) and Congress of Neurological Surgeons (CNS) stated that, Helmet therapy is recommended for infants with persistent moderate to severe plagiocephaly after a course of conservative treatment (repositioning and/or physical therapy) (Tamber, et al.). This patient presented with mild plagiocephaly with a cranial vault asymmetry (CVA) of 9.0 mm and cephalic index (CI) of 82.8. The patients cranial asymmetry was 1.8 standard deviations from the mean. The patients physical presentation supports a diagnosis of mild plagiocephaly. The records indicate that treatment included repositioning attempts for 0.75 months prior to treatment with the cranial remolding orthosis. In the absence of severe plagiocephaly or brachycephaly, and documentation of limited attempts at conservative treatments, the use of a cranial orthosis is not recommended. Thus, the cranial remolding orthosis was not medically necessary to treat this patient.   Final Result: The reviewer determined that the device issue was 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 subspecialty certification in pediatric critical care 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 63-year-old male enrollee has requested Leukine for the treatment of his neutropenia associated with chemotherapy. Findings:  The physician reviewer found that the American Society of Clinical Oncology guidelines state that reduction in febrile neutropenia is an important clinical outcome that justifies the use of colony-stimulating factors, regardless of impact on other factors, when the risk of febrile neutropenia is approximately 20% and no other equally effective regimen that does not require colony-stimulating factors is available. These guidelines also state that primary prophylaxis is recommended for the prevention of febrile neutropenia in patients who are at high risk based on age, medical history, disease characteristics, and myelotoxicity of the chemotherapy regimen. The National Comprehensive Cancer Network guidelines have taken a similar stand on the use of prophylactic growth factors. They recommend prophylactic growth factors with regimens with a moderate to high risk of neutropenia, or in cycles following an episode of febrile neutropenia. The incidence of neutropenia associated with the proposed regimen has not been established in clinical trials. However, based upon similar regimens, the intensity of neutropenia is moderate and would meet the guidelines for use of Leukine. As such, Leukine is medically indicated for this patient.
Appeal type: Medical Necessity
Decision: Upheld

A 44-year-old male enrollee has requested for Genotropin growth hormone therapy for treatment of his panhypopituitarism.  Findings:  The physician reviewer found that the records do not demonstrate the basis for the diagnosis of growth hormone (GH) deficiency or panhypopituitarism. The only clinical symptom reported is fatigue. the differential diagnosis of fatigue includes many other conditions that need to be ruled out before there is adequate evidence of panhypopituitarism. The patients medical records do not include a past medical history of pituitary disease, damage, hypophysectomy, or history of childhood GH deficiency.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a three-year-old male enrollee requested authorization and coverage for speech therapy. The health plan has denied this request indicating that the requested therapy is not medically necessary for treatment of the enrollees apraxia of speech.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the health plans denial on the basis that the requested speech therapy is medically necessary.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for corneal collagen cross-linking. Findings:  Two of three physician reviewers found that there is sufficient support for the services at issue in this clinical setting. Collagen cross-linking has been approved by the U.S. Food and Drug Administration for halting the progression of keratoconus. A key question that determines whether a patient should be treated is whether the keratoconus is still progressing. This can be established by a history of progressive blurriness and/or by serial testing. In this case, the patient has reported progressive blurriness in the right eye. More importantly, the patients young age and keratometry is consistent with a high risk of progression. Therefore, corneal collagen cross-linking was likely to have been of greater benefit than other treatment options. Final Result: The reviewers determined that the services at issue were likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in ophthalmology 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: Overturned

A 61-year-old male enrollee has requested stereotactic radiosurgery (CPT code 61796  SRS Cranial Lesion Simple and CPT code 61797  SRS Cranial Lesion Simple ADDL) for treatment of his metastatic rectal cancer with brain metastasis.  Findings:  The physician reviewer found that the submitted documentation establishes the medical necessity of the requested procedure. Stereotactic radiosurgery is a well-accepted treatment in patients with 1-3 brain metastases, less than 4cm in size. Stereotactic radiosurgery is a procedure in which a single, high dose of radiation is delivered to a well-defined volume, using a stereotactic head frame for patient immobilization and tumor localization. It is used for both benign and malignant tumors of the brain. Stereotactic radiosurgery is standard therapy and there is an abundance of medical studies documenting its safety and efficacy. Patients may undergo several courses of radiosurgery, either to the same target (if the metastasis progresses despite initial radiosurgery) or different targets which may develop between radiosurgeries. All told, it is consistent with medically accepted standard practice to treat this patient with radiosurgery and therefore the requested procedure is medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Humira Pen 40 mg/0.8 ml pen injection kit.Findings:  The physician reviewer found that that the submitted documentation fails to demonstrate the medical necessity of the requested medication. This patient has a history of generalized granuloma annulare.  Treatment of generalized granuloma annulare is difficult. The records indicate that this patient has tried and failed treatment with topical steroids, ultraviolet B therapy, methotrexate, and isotretinoin. Additional therapies for the treatment of granuloma annulare include hydroxychloroquine, chloroquine, dapsone, and cyclosporine.  As the standard first-line and second-line therapies have not been tried, and the requested medication has not been adequately studied in the treatment of granuloma annulare, Humira Pen 40 mg/0.8 ml pen injection kit 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 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

Nature of Statutory Criteria/Case Summary:   An enrollee requested continued residential treatment for treatment of her medical condition.   Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the services at issue.  The patient had long struggled with mood symptoms and had profound eating disordered behaviors.  She had physical sequelae from her eating disorder, and both psychiatric and medical comorbidity.  Per the medical records, discharge at this time would have been premature and more than likely would have resulted in undue morbidity and prompt readmission.  The patient had not yet consolidated the treatment gains necessary to succeed in a less restrictive setting.  The duration of services for a case of this complexity was consistent with community standards.  Finally, the entire course of care was reasonably expected to improve her condition and prevent a more serious episode of illness.  All told, continued residential treatment was medically indicated for the treatment of this patient.  Final Result: The reviewer determined that the services at issue were 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 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: Upheld

A 61-year-old male enrollee has requested imaging studies and laryngeal function studies for evaluation of the enrollees sleep apnea and snoring.  Findings:  The physician reviewer found that after failing a trial of CPAP therapy for treatment of his obstructive sleep apnea, the patient underwent some studies at a treatment center for craniofacial pain. It appears these studies were performed at the time the patient was being fitted for the dental appliance. There is documentation of a pharyngometer laryngeal study and several x-rays including x-rays of the cervical spine and nasal bones. These diagnostic modalities are not included within mainstream evaluation and treatment of sleep apnea. The clinical value of the services at issue has not been established in this setting. As such, the use of these modalities was not medically justified in this case.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting authorization and coverage for Prolia injections. The enrollee has osteoporosis, osteoarthritis, and rheumatoid arthritis. She is on high doses of prednisone. Her medical history includes a diagnosis of glioma. A progress note indicated the enrollee has pain in multiple joints and her back. She has difficulty holding things and difficulty maneuvering. She reports muscle cramping. Records show the enrollees calcium level was 8.8. The assessment indicated age-related osteoporosis without current pathological fracture. She was prescribed Prolia, 60 nanograms per milliliter injections, to be given every six months. The physician indicates the enrollee cannot take bisphosphonates as she has had side effects, with very high creatine phosphokinase levels. The physician reports the enrollee is at high risk for fracture. Literature reports chronic glucocorticoid use causes bone loss; therefore, treatment with Prolia is justified, even if the enrollee only has osteopenia. Literature shows Prolia is approved for steroid-induced osteoporosis, and provides better improvement in bone density than bisphosphonates. Studies show denosumab significantly increased lumbar spine and hip bone mineral density, when compared to bisphosphonates.Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in endocrinology, diabetes and metabolism 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.