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

The parent of a three-year-old female enrollee has requested speech therapy for treatment of the enrollees medical condition.  Findings:  The physician reviewer found that the submitted documentation establishes the medical necessity of the requested therapy.  Based upon the documentation provided, the patient is language delayed. The patients pediatrician is in accordance with the medical community, whose customary and usual practice would be to refer this patient for speech evaluation and therapy. Children under the age of four can readily learn multiple languages; after the age of four the brain has much less capacity to absorb and learn a new language, thus the patients language delay cannot be attributed to her exposure to dual language. Furthermore, the medical literature provides support for speech therapy in this clinical setting. The meta-analysis by Law and colleagues reported that children with speech delay can be readily and successfully treated. Goorhuis-Brower and Knijff discussed the effect of speech therapy on language comprehension, language production and nonverbal functioning with children with developmental language disorders and the authors emphasized that normal, as well as cognitively delayed children, are candidates for successful speech therapy. Therefore, based on the medical literature cited above and documentation submitted for review the medical necessity of the requested speech therapy has been established in this clinical setting.
Appeal type: Medical Necessity
Decision: Overturned

A 29-year-old female enrollee has requested Gilenya for treatment of her multiple sclerosis. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested medication.  This patient has multiple sclerosis and requires disease modifying therapy.  Injection therapies are uncomfortable, and lack of adherence to treatment reduces clinical benefits.  Verdun di Cantogno and colleagues noted that barriers to self-injection include needle phobia and concerns over correct injection technique.  Given this patients needle phobia, she is less likely to adhere to treatment with injection therapy.  The current medical evidence has established the efficacy of Gilenya in this clinical setting.  All told, Gilenya is medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

A 40-year-old male enrollee requested authorization and coverage of facial reconstruction by means of liquid silicone injections for the treatment of lipoatrophy.  The Health Plan denied the enrollees request indicating that the requested treatment is not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer overturned the health plans denial on the basis that the requested injections are medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 12-year-old girl who developed Type I Diabetes Mellitus in November 2004. The patient was not over-weight and she had a goiter. The submitted blood glucose records indicate that the patient is passing her honeymoon period and is entering the stage of higher blood glucose levels. This is the stage that insulin pumps are often recommended. There is no evidence in the submitted documentation that an insulin pump has been requested by the patients provider. At issue is whether an insulin pump is medically necessary for treatment of the patients medical condition.It does not appear the patients providers have submitted a request for an insulin pump. The Health Plan indicates an insulin pump would be authorized if a request for the pump was made by the diabetes team caring for the patient. The patients mother wishes to receive an insulin pump for her daughter in order to diminish the number of sticks the patient has to receive each day. In actuality, the pump would only diminish the number of insulin shots the patient receives. In any event, approval of the request for an insulin pump necessitates that the request is made by skilled health care providers who have determined that the patient and her parent need the device and are able to operate it appropriately. In this case there is insufficient evidence an insulin pump is considered medically necessary by the patients diabetes team. Therefore, I have determined the requested equipment is not medically necessary for treatment of the patients medical condition. Accordingly, the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for proton beam therapy. Current guidelines do not endorse the routine use of proton therapy in the treatment of all patient with Hodgkins lymphoma (Allen, et al.; Dabaja, et al.). Treatment of Hodgkins lymphoma generally consists of photon techniques utilizing intensity modulated radiation therapy (IMRT) and image guidance using breath hold techniques to minimize dose to the heart and lungs. However, in this patients clinical scenario, the field of treatment encompasses the entire anterior chest wall including the heart and lungs. Comparative dosimetry was performed, and proton therapy was able to significantly spare the mean heart dose by 50%. This reduction is sufficient data to support treatment with proton therapy with substantially improved sparing of the heart compared to standard IMRT with photon techniques (Hoppe, et al.). Treatment with proton therapy for this patient is expected to decrease long-term cardiac toxicities compared to IMRT with photon techniques. Therefore, the requested proton beam therapy is medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in radiation oncology 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 42-year-old female enrollee has requested growth hormone therapy (Genotropin injectable) for treatment of her growth hormone (GH) deficiency.  Findings:  The physician reviewer found that AACE Guidelines state that most adults selected for GH therapy should have an easily recognizable cause, clear cut clinical features of the adult syndrome and nonrefutable laboratory evidence of GH deficiency. The guidelines further state that a test using arginine and GH-releasing hormone has been determined to be more stringent than tests using arginine or L-dopa alone. Other studies indicate that in patients with multiple pituitary hormone deficiencies, GH deficiency is so likely that stimulation testing is not necessary. In this case, we are told that the IGF-1 was low in 1999, but we are not told what the original IGF-1 level was. Additionally, a non-preferred stimulation test was performed. The clinical notes indicated that L-dopa and arginine were used as stimulation agents, however the laboratory report provided pertains only to L-dopa.Isolated growth hormone deficiency is a rare diagnosis in adults. In this instance we do not have obvious pituitary or hypothalamic disease documented by history, surgery or MRI and there is no evidence of anatomical abnormalities or other hormone deficits. It would seem reasonable at this juncture to perform a preferred stimulation test with arginine/GH releasing hormone while off of GH therapy to document a GH deficiency. At the present time,  the use of Genotropin is not medically appropriate.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 20-year-old woman who has severe bilateral axillary hyperhidrosis. Treatment courses of Xerac AC and Drysol have been ineffective. The patient stated that the hyperhidrosis has been so severe that she experiences large areas of clothing stains that are noticed by others. She received Botox injections in February 2005 and her provider has recommended a repeat course of the therapy. The Health Plan has denied coverage for additional treatment with Botox on the basis it is not medically necessary for treatment of the patients condition.Review of the submitted clinical evidence demonstrates the patients hyperhidrosis is severe. Erosion, maceration or ulceration of the skin is not the sole criterion for assessing whether treatment of this condition is medically necessary. Interference with daily functioning and impact on quality of life are also valid standards and should be considered. Treatment of the patients severe axillary hyperhidrosis is medically warranted. Initial therapy with Xerac AC and Drysol has been ineffective. Therefore, Botox therapy is the next appropriate treatment step and should be authorized. Based upon the information set forth above, I have determined that the requested therapy is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

A 56-year-old female enrollee has requested authorization and coverage for left total hip replacement surgery.  Findings:  The physician reviewer found that the submitted documentation demonstrates the medical necessity of the requested procedure in this patients case.  Total hip arthroplasty has been generally accepted as an efficacious procedure for advance osteoarthritis of the hip, with a low risk of failure and durable fixation in patients with advanced disease, or patients who have had a failure of conservative management.  The most common indication for the procedure is the presence of pain, classically located in the groin, and reliably relieved by the procedure.  In this patients case, the diagnosis of advanced degenerative disease was confirmed by x-ray.  Additionally, the medical records document significant pain.  The current medical evidence supports the requested procedure in this clinical setting.  All told, the requested left hip replacement is medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

A 58-year-old female enrollee has requested Botox injections for the treatment of her migraine headaches. Findings:  Three physician reviewers found that although Botox has been used in select cases of migraine headache, it is not considered a first-line therapy for migraine prevention. While this patient has used Imitrex and Maxalt for abortive therapies, there is only evidence of a trial of one prophylactic medication, amitriptyline. There are many other better studied and proven migraine therapies that have not been attempted by this patient. The American Academy of Neurology Quality Standards Subcommittee practice parameters for headache care suggest that there are more standard alternatives that may prove efficacious for this patient.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has been diagnosed with Behcets disease. The provider noted the patient was HLA-B51 positive. She has had three episodes of genital ulcers and two episodes of oral ulcers that spontaneously resolved. The patient reported arthralgia/myalgia in the joints of the back, cervical spine, ankles, and feet. The patient also reported fatigue, weakness, and weight loss. Ulcers were not noted on physical examination. The patient has requested authorization and coverage for Otezla. The Health Plan denied the request and reported the requested medication is not medically necessary for the treatment of this patient. At issue in this case is whether Otezla is medically necessary for the treatment of the patients medical condition. Authors reported, Topical measures such as steroids should be used for the treatment of oral and genital ulcers. Colchicine should be tried first for the prevention of recurrent mucocutaneous lesions, especially when the dominant lesion is erythema nodosum or genital ulcer. Papulopustular or acne-like lesions are treated with topical or systemic measures as used in acne vulgaris. Leg ulcers in Behcets syndrome might be caused by venous stasis or obliterative vasculitis. Treatment should be planned with the help of a dermatologist and vascular surgeon. In this case, there were no objective findings of oral or genital lesions in the provided medical records to support treatment with Otezla. The patients symptoms included myalgia, arthralgia, fatigue, and weight loss. The medical evidence does not support the requested medication in this clinical setting. Therefore, Otezla 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 in rheumatology 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: The parent of an enrollee has requested reimbursement, and authorization and coverage for private duty nursing in the home (CPT code S9124). The submitted documentation supports the medical necessity of the requested services. The American Academy of Pediatrics supports home health nursing care for patients with skilled multi-system care needs. In this case, skilled nursing care is required to administer medications and nutrition through the G-tube, and to monitor vitals and lungs in order to prevent aspiration pneumonia and other complications. Care by a skilled nurse is required to administer the medications in a correct dose and frequency. Under these circumstances, private duty nursing in the home (CPT code S9124) was, and is, medically necessary for treatment of the enrollees medical condition.Final Result: The reviewer determined that the requested services were, and are, medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in pediatrics and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a seven-year-old male enrollee has requested for an MRI of the brain for evaluation of her attention deficit/hyperactivity disorder (ADHD) and bipolar aggressive behavior. Findings:  The physician reviewer found that the accepted uses for MRI include musculoskeletal, cardiovascular, oncological and neurologic imaging.  The accepted neurological uses include acute onset of neurological signs and findings, new transient neurologic signs and findings, headache, seizure, trauma, follow-up of intracranial abscess and primary brain tumor, evaluation  for brain metastases, evaluation of arteriovenous malformation, post intracranial procedure/craniotomy, suspected central nervous system involvement with systemic disease, suspected neurodegenerative disorder, suspected hydrocephalus, non-acute onset mental status changes and macrocephaly and microcephaly.
Appeal type: Experimental/Investigational
Decision: Upheld

 A 29-year-old male enrollee requested authorization and coverage of surgical debulking,  removing appendix, insertion of porta-cath and clinical trial, for the treatment of abdominal cancer.  The health plan denied the enrollees request indicating that the requested treatment is experimental.Three physician reviewers performed an experimental/investigational Independent Medical Review.  Each of the three physician reviewers concluded that surgical debulking is not likely to be more beneficial for treatment of the enrollees abdominal cancer than any available standard therapy.  Because all three physician reviewers concluded that the requested treatment is not likely to be more beneficial for treatment of the enrollees medical condition than any available standard therapy, the review organization upheld the health plans denial.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a two-year-old male enrollee has requested for speech therapy for treatment of the enrollees speech delay. Findings:  The physician reviewer found that the current medical evidence supports the requested services in this patients case.  As noted by Nelson and colleagues, speech and language development is considered by experts to be a useful indicator of a childs overall development and cognitive ability and is related to school success.  The authors noted that identification of children at risk for developmental delay or related problems may lead to intervention services and family assistance at a young age when chances for improvement are best.  Speech and language delay must be taken seriously in young children, because the long-term consequences may be substantial.  According to Law and colleagues, approximately 6% of children have speech and language difficulties.  Per Law and colleagues, children whose difficulties persist into primary school may have long-term problems concerning literacy, socialization, behavior, and school attainment.  These reviewers concluded that there is a positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulties.  Children who are born prematurely are at significant risk for delays in normal development, the etiology of which is most likely due to a combination of prenatal, neurologic, and environmental factors.  This patient was born prematurely and has significant language deficits, most prominent in his expressive language skills.  This is severely impacting his ability to communicate in a functional and age-appropriate manner.  Studies have shown that speech and language therapy can result in significant improvement in this clinical setting.  All told, speech therapy is medically necessary in this patients case.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 29-month-old female enrollee has requested speech therapy, occupational therapy and physical therapy services for treatment of the enrollees developmental delays.   Findings:  The physician reviewer found that speech therapy is medically necessary and appropriate to address this patients delays in speech and language skills. According to a Cochrane Database meta-analysis of 25 studies, approximately 6% of children have speech and language difficulties. Whilst most childrens difficulties resolve, children whose difficulties persist into primary school may have long-term problems concerning literacy, socialization, behavior and school attainment. (Law, et al.) These reviewers concluded that overall there is a positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulties. Bernhardt and Major concluded that early phonological and metaphonological intervention can promote normalization of speech development and normal acquisition of literacy skills for at least some children with a history of severe phonological impairment. Finally, in a recent review of therapeutic intervention for children with speech and language delay, McLaughlin concluded that there are good data available to support the effectiveness of speech-language therapy, particularly for children with primary expressive language disorder. Occupational therapy is also medically necessary and appropriate to address this patients delays in fine motor skills and self-help skills. The patient has delays in fine motor skills, adaptive/self-help skills, and social skills. With its focus on teaching self-help skills and facilitating development of fine and gross motor skills, occupational therapy is well suited to affect positive change in this patient. Finally, physical therapy is medically necessary and appropriate to address this patients delays in her gross motor skills. As a result of hypotonia and low muscle tone, the patient has gross motor deficits impacting acquisition of stationary and locomotion skills. Physical therapy is ideally suited to optimize this patients gross motor skills, including locomotion, balance, and other deficits. In conclusion, this patient, who has hypotonia of an unclear etiology, has made gains during her therapy at the local regional center. However, she continues to fall behind her peers in all areas of development and acquisition of functional skills. Therefore, continued speech, occupational, and physical therapies are medically necessary and appropriate.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for follow-up eye surgery. Findings:  The physician reviewer found that, according to the medical records provided for review, the patient has had treatment for complicated retinal detachment. Although the patient has recovered from the surgery, her provider noted that she has poor prognosis for additional improvement with further surgery. The evaluation demonstrated that the right eye condition is stable. Thus, the requested follow-up eye surgery is not supported as medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the requested surgery 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 ophthalmology 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 74-year-old female enrollee has requested Procrit for the treatment of her anemia secondary to diabetes mellitus. Findings:  The physician reviewer found that since the cause of the anemia has not been medically evaluated for possible causes, such as chronic renal failure with loss of endogenous erythropoietin, underlying cancer, or other marrow disorders, it is not possible to conclude that the Procrit is medically necessary for this patient. It seems clear that were a cause of the anemia identified by proper medical evaluation, it is likely that the cause would support the continued use of Procrit. However, the possibility remains that the medical evaluation might uncover a cause of anemia that should be treated by other therapy than Procrit. Thus, at this time, without further medical evaluation of the cause of this anemia, this medication cannot be supported as being medically necessary.