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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for testosterone transdermal gel (one percent) 50 milligrams per 5 grams. The submitted documentation does not support that the requested medication is medically necessary. In this case, the patient has a prolactin secreting pituitary tumor and currently is on cabergoline therapy with prolactin levels decreasing. Although the patient was seen to have multiple testosterone levels which were below the normal reference range, there was no time stamp for the lab draws, and the lab draws do not reflect if the reported testosterone levels were done in the morning. Accordingly, the submitted laboratory documentation is not sufficient to establish the diagnosis of hypogonadism at this time. Under these circumstances, the request for testosterone transdermal gel (one percent) 50 milligrams per 5 grams is not 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 internal medicine, with subspecialty certification in endocrinology, diabetes and metabolism. 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

The patient is a 16-year-old female with a significant history of obesity and family obesity. She is reported to weigh 300 pounds with a BMI of 44. She has been overweight since age seven. She has made multiple attempts at non-surgical weight loss without success and with weight gain. She has comorbidities including hypertension and asthma. The patients mother has requested authorization for gastric bypass surgery to treat the patients morbid obesity.Although there are surgeons and surgical centers specializing in bariatric surgery for adolescents, there is a limited amount of scientific evidence regarding bariatric surgery in adolescent patients. Significant concerns involving adolescent patients and bariatric surgery include growth retardation and behavior modification. If treated with bariatric surgery, adolescents should only undergo restrictive operations such as proximal gastric bypass.Given the potential for growth retardation and the fact that there is no evidence the patients growth plates are closed, weight loss surgery is not indicated for this patient. Furthermore, the patients continued failure of non-surgical weight loss attempts and actually gaining weight creates concerns regarding the patients ability to modify her behavior appropriately after gastric bypass surgery. Moreover, bariatric surgery for adolescents is not considered standard of care. When it is confirmed that the patients growth plates are closed and that the patient has a full understanding of lifestyle changes necessary for the success of bariatric surgery and the ability to implement those changes, surgery may be appropriate for this patient.Based upon the information set forth above, I have determined the requested procedure is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

This patient is a seven-year-old female with a diagnosis, by mothers report, of pervasive developmental disorder.  She has related speech deficits including pragmatic speech delay.  The patient scored two standard deviations below the mean (fifth percentile) in two subtests of the CLEF-4 (concepts and following directions and recalling sentences) and is eligible for speech therapy through the school system.  The patient has been receiving private speech therapy where the CLEF-4 was also administered. That testing report appears to be associated with an evaluation dated January 2006, but the report itself is not dated. The patient had lower scores for formulated sentences and word structure with the earlier test administration. The patients parent has requested authorization for continued speech therapy. The Health Plan denied the request based upon a determination that the therapy is not medically necessary.In reviewing the patients private speech therapy progress notes and evaluations, I cannot discern functional gains or apparent improvement. Specifically, the Objectives as outlined in the progress summary and treatment plan dated January 2006, are identical to the objectives outlined in the November 2005 treatment plan.  Most of the objectives appear to have been achieved prior to January 2006 and the remaining goals show no incremental increase in the progress made. As such, the functional gain essential to a determination of medical necessity, cannot be established.Based on the evidence cited above, I have determined the requested therapy is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Overturned

The parent of a fourteen year-old male is requesting reimbursement for a Magnetoencephalography (MEG) study.  The patient is being evaluated through a university epilepsy program for possible surgical intervention. PET, EEG and MRI have given somewhat conflicting results regarding seizure focus.Reviewers Findings:One of the three reviewing physicians found that the MEG remains an experimental and investigational technology. The patients seizure foci were identified via EEG and PET, and MEG did not add new information, nor was it likely to alter the patients care.  This reviewer found that the Health Plan denial should be upheld.  Two of the three reviewing physicians found that MEG is a generally accepted diagnostic tool at major epilepsy surgery centers due to its ability to identify deep seizure foci.  Because of this information these reviewing physicians found that the Health Plan denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

A 51-year-old female enrollee has requested for rituximab (Rituxan) for treatment of her neuromyelitis optica.  Findings:  The physician reviewer found that Rituxan is widely used in the management of patients with NMO at MS centers throughout the country. As NMO is a rare disorder, there will not likely ever be an adequate double blinded trial, thus the available scientific data is not in the form of randomized, double-blinded controlled trials. The discovery alone of the Antiaquaporin 4 antibody as the etiologic cause of NMO enabling differentiation from MS is itself a recent event. The largest trial of Rituxan in 2008 did suggest a very high efficacy with positive outcomes. Jacob and colleagues concluded that, In NMO, treatment with rituximab appears to reduce the frequency of attacks, with subsequent stabilization or improvement in disability. Since NMO is an autoimmune disorder, it requires treatment with immunosuppressive therapy.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a three-year-old male has requested speech therapy for treatment of his expressive language delay.  Findings:  The physician reviewer found that the patient has an identified expressive speech delay of approximately 50%.  Speech therapy is indicated with any delay greater than 25% (Law, et al.). Improvements have been noted following speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulty (Law, et al.). Treatment for language disorders is predicated primarily on the childs language profile and level of communication skills (Feldman and Messick). Children who participate in speech-language treatment show better improvement than those children who receive no treatment (Feldman and Messick). Gallagher and colleagues evaluated speech and language interventions for preschool children with specific language impairment and found statistically greater improvement with intensive direct speech therapy delivered by speech and language therapists over an eight-month period when compared to no intervention or nursery-based intervention. This patient has made significant progress in his receptive language skills with intervention and is likely to benefit from continued therapy.
Appeal type: Medical Necessity
Decision: Upheld

Findings:  The physician reviewer found that this patient has a medical history of type two diabetes, hyperlipidemia and onychomycosis. The patient presented as a new patient with complaints of onychomycosis. She has been treated with topical Jublia in the past with noted improvement to her toenails. The physical examination revealed onychomycosis on toes one through five on bilateral feet, ingrown nail to the left great toe/medial border as well as dry flaky skin with scaling and itching to bilateral feet. The provider reported the patients toenails were debrided at this visit, and a prescription was dispensed for Jublia. At issue in this case is whether the requested medication Jublia, is medically necessary for treatment of the patients medical condition. The British Association of Dermatologists guidelines for the management of onychomycosis advise that problems associated with onychomycosis include discomfort, difficulty in wearing footwear, difficulty walking, and lowered self-esteem. The guidelines also advise that approximately half of all patients with onychomycosis experience pain or discomfort with about 30% of the patient population have difficulty in wearing footwear. In this case, it is well-established that this patient has onychomycosis toenails. The patient has advised in the medical record that she is unable to take oral medications for onychomycosis due to the possibility of liver side effects. However, there is no documentation that this patient has attempted other topical medications for her condition. Furthermore, there is no documentation that this patient complains of pain from onychomycosis. There is no documentation of palpable pain to the toenails and toenail area during the physical examination or that the onychomycosis causes pain with ambulation or wearing footwear. Therefore, Jublia is 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 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

A 31-year-old female enrollee requested authorization and coverage for a panniculectomy. The health plan has denied this request indicating that the requested procedure is considered cosmetic and not medically necessary for treatment of the enrollees low back pain, chronic infections, rashes and sores within the lower abdominal skin fold.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 considered cosmetic and is not medically necessary.  The reviewer cited a lack of significant documentation of medical problems associated with the panniculus.
Appeal type: Medical Necessity
Decision: Upheld

A 48-year-old female enrollee has requested an MRI of the lumbar spine (CPT code 72158) and an MRI of the cervical spine (CPT code 72156) for evaluation of her medical condition. Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the services requested. The patient presented with axial pattern (non-radiating) cervical and lumbar complaint with no indication that this represents radiculopathy, tumor, infection, weakness or undiagnosed trauma. Additionally, the patients bowel function problems are consistent with her diagnosis of irritable bowel syndrome and do not appear to be secondary to a cauda equina syndrome. In the absence of evidence suggesting the presence of a neoplasm, infection, radiculopathy, unilateral weakness, atypical pattern pain or bowel or bladder function changes attributable to a potential cauda equine syndrome, MRI of the cervical and lumbar spine is not clinically indicated. All told, the medical necessity of the requested MRI studies has not been established.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 61-year-old male who apparently became dependent on narcotic pain medications following a back injury in January 2005.  There is no other history of substance abuse/dependence noted in the record. The patients symptoms of withdrawal were noted to included dyspepsia, back pain, tension, nervousness, anxiety, diaphoresis, tremors and sleep disturbance.  Reportedly, attempts at detoxification through the Health Plan failed.  The patient received non-plan treatment with Suboxone in January 2006 and is now requesting reimbursement.  The Health Plan denied his request based on a determination that Suboxone detoxification was not medically necessary.The patient has thoroughly researched the treatment options available for opiate detoxification and would appear to meet the criteria for medically supervised withdrawal. In comparison to other detoxification regimens, Suboxone is known to result in less severe symptoms of withdrawal.  In addition, the opiate detoxification can be accomplished on an outpatient basis and over a shorter period of time.  Therefore, I have determined the therapy at issue was medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 67-year-old male with Kugelberg Welander syndrome. He is a quadriplegic with a tracheostomy tube. The patient indicates that his current power-operated wheelchair is too loud, not fast enough, and damages the woodwork in his home. The patient has requested upgrades to the wheelchair that include replacement of the wheels and an upgraded motor. The Health Plan has denied the patients request indicating that the requested upgrades are not medically necessary.The patient has requested upgrades to his power-operated wheelchair that would allow him a quieter motor and different wheels, as well as faster speed. However, based on the documentation provided the patient is able to perform his activities of daily living with his current wheelchair. He is able to maneuver his wheelchair within his home and can use it for mobility within the community. Thus, the patients current wheelchair meets the patients medically necessary needs for his condition. There is no evidence that the requested upgrades are medically necessary.Based upon the information set forth above, I have determined that the requested equipment is not medically necessary for the treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:   An enrollee has requested an Otto Bock Genium X3 microprocessor-controlled knee for treatment of her medical condition.  Findings:  The physician reviewer found that the Otto Bock Genium X3 microprocessor-controlled knee is medically necessary for treatment of the patients medical condition. Researchers have concluded The Genium knee generally increases flexion in swing and stance, potentially decreasing the level of impairment for persons with transfemoral amputation. This study demonstrates functional differences between the C-Leg and Genium knees to help prosthetists determine if the Genium will provide functional benefits to individual patients. In addition, researchers compared the C-Leg and Genium microprocessor-controlled knees concluding that Results showed that use of the Genium facilitated a more natural gait biomechanics and load distribution throughout the affected and sound musculoskeletal structure. This was observed during quiet stance on a decline, walking on level ground, and walking up and down ramps and stairs.  In sum, the literature demonstrates that the C-Leg and Genium knees are not equivalent. Therefore, the request for Genium knee is medically necessary for the treatment of this high functional patients amputation.  Final Result: The reviewer determined that the requested device 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 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: The patient has requested authorization and coverage for immune globulin therapy. The records provided for review state that the patients cognition and pain have improved with immunoglobulin replacement therapy. However, there is a lack of evidence in the current medical literature to support the treatment of decreased cognition, severe fatigue and neuropathy with immunoglobulin replacement therapy. The patients records do not document a specific diagnosis to support an indication for immune globulin or recurrent sinopulmonary infections. In addition, although the patient had inadequate pneumococcal antibody titers two years ago, she had adequate response with greater than 70% protective antibody titers a year ago. Given these findings, immune globulin therapy is not medically necessary for 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 subspecialty certification in allergy and immunology 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 62-year-old female enrollee has requested for pelvic floor stimulation for treatment of her urinary frequency, urgency and urinary incontinence. Findings:  Two physician reviewers found that as noted by Dumoulin and colleagues, the optimal pelvic floor muscle training regimen for achieving continence remains unknown.  The authors noted that many questions regarding pelvic floor muscle training remain, including the frequency of pelvic floor muscle training and the number of contractions that should be performed for maximal effect. The authors noted that the actual regimen of pelvic floor muscle training used varied widely in randomized controlled trials.  In this patients case, the superior efficacy of the services at issue has not been established.
Appeal type: Experimental/Investigational
Decision: Upheld

A 61-year-old female enrollee has requested for antigen therapy for treatment of her medical condition.   Findings:  Three physician reviewers found that the American Medical Association Council on Scientific Affairs notes that some patients present to physicians with symptoms that cannot be attributed to any known condition, disorder, or disease. Further, they may have no physical findings or laboratory abnormalities to support a standard diagnosis. Physicians who practice clinical ecology associate these symptoms with repeated exposure of susceptible individuals to very low levels of substances that exist in the environment or are ingested as food or liquids. After these substances have accumulated to a threshold concentration in the body, they are purported to produce immune dysfunction and result in a generalized clinical disorder, multiple chemical sensitivity syndrome. The American Academy of Allergy, Asthma and Immunology states, There is no clear evidence that the diseases and symptoms listed are related to allergy, sensitivity, toxicity, or any other type of reaction from food, water, chemicals, pollutants, or microorganisms (see Resiman).
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Nutropin AQ Nuspin Pen Injector. Findings  The physician reviewer found the submitted documentation supports that the requested medication is medically necessary. According to published guidelines, a trial of growth hormone (GH) therapy should be approved for children with otherwise unexplained short stature who pass GH stimulation tests but who meet most of the following criteria: (1) height more than 2.25 standard deviations (SDs) below the mean for the age or more than two (SDs) below the mid-parental height percentile; (2) growth velocity less than 25th percentile for bone age; (3) bone age more than two SDs below the mean for age; (4) low serum insulin like growth factor-1 (IGF-1) and/or insulin like growth factor binding protein-3 (IGFBP-3); and/or (5) other clinical features suggestive of GH deficiency. This patient meets above criteria. Final Result: The reviewer found 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 pediatrics with subspecialty 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.