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

A 61-year-old female enrollee has requested an electric scooter for treatment of her mobility difficulties. Findings:  The physician reviewer found that scooters/power operated vehicles are considered medically necessary when the individual requires the device in order to safely perform activities of daily living in the home setting, as noted by Dicianno and Tovey. In addition, an individual must demonstrate both a willingness and capacity to safely operate the requested scooter in the home environment. In the case under review, the patient has not provided documentation that supports her need for a scooter to perform her activities of daily living or her capacity to safely operate such a vehicle. Although no formal evaluation of her functional mobility has been provided, the notes available for review indicate that she is capable of ambulating with the use of a cane. An electric scooter is not necessary for the patients ambulation within the home.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for bilateral breast augmentation. Bilateral breast augmentation is medically necessary for many transgender females to help alleviate the psychological distress they experience related to gender dysphoria. The World Professional Association for Transgender Health (WPATH) supports breast augmentation to help alleviate the distress associated with an incongruent physical appearance and gender identity. WPATH noted that non-genital surgical procedures are oftentimes of greater practical significance in the patients daily life than reconstruction of the genitals. The guidelines further report that, These reconstructive procedures are not optional in any meaningful sense but are understood to be medically necessary for the treatment of the diagnosed condition. The records provided for review document that this patient is committed to feminine transformation as evidenced by her treatment with feminizing hormones. The patient reports persistent gender dysphoria related to masculine facial features associated with social dysfunction. The patient meets the WPATH criteria for gender dysphoria and indication for bilateral breast augmentation based upon clinical documentation of her gender dysphoria and related distress. Given these findings, the requested bilateral breast augmentation is supported by the WPATH as 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 psychiatry with expertise in transgender health 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 57-year-old female enrollee requested the Butrans Patch 5 mcg/hr, one patch per week for medical treatment of her osteoarthritis and fibromyalgia.   Findings:  The physician reviewer found the current standard of care for chronic pain associated with osteoarthritis and fibromyalgia is treatment in a multidisciplinary practice to include physical therapy, massage therapy, behavioral therapy, and injections to help reduce pain (Fishman). Baron and McDonald reported that high dose opiates might contribute to pain sensitization via opioid-induced hyperalgesia, decreasing patient pain threshold and potentially masking resolution of a preexisting pain condition.  All told, the requested Butrans Patch 5 mcg/hr, one patch per week is not supported as medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 31-year-old female enrollee has requested partial hospitalization program services for treatment of her anorexia.  Findings:  The physician reviewer found that medical documentation from the dates in question reflects significant impairment with body image distortion. Based on a documented history of continued laxative abuse and restricting, along with the need for supervision of meals, and medical factors such orthostatic tachycardia, partial hospitalization program services were warranted. The patient was at risk for an exacerbation of her symptoms at a lower level of care.  The American Psychiatric Association guidelines indicate that partial hospitalization program services are warranted when the patient is preoccupied with intrusive and repetitive thoughts regarding the eating disorder greater than three hour per day and when there is a need for structure and meal supervision.  Both were evident in this case. For patients with anorexia, a decision regarding level of care is not based on weight alone, but must take into consideration the presence of additional stressors and the degree to which the patient can effectively participate in her care in a less supervised setting.  All told, partial hospitalization program services provided during the time period were medically indicated for this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested prolotherapy (platelet rich plasma injections) for treatment of her medial knee pain. Findings:  Three physician reviewers found that according to the available scientific literature, the use of platelet-rich autologous blood or plasma therapy has not proven to be an effective treatment for meniscal pathology, ligamentous knee injury, chondral knee injury/pathology, patellofemoral syndrome, knee arthropathy or any other knee condition. There are very limited published high-grade clinical studies to support the efficacy of autologous platelet-rich plasma injections for any of these or other musculoskeletal conditions with respect to any clinically or functionally relevant outcomes. Multiple reviews have concluded that there is a lack of high-grade evidence to support the efficacy of this intervention.  Given the lack of high quality medical literature establishing its effectiveness, prolotherapy (PRP injection) remains an unproven therapy at this time. There is also a lack of evidence that it favorably modifies the clinical course of any musculoskeletal condition greater than a placebo effect. The knee injury sustained by this patient is a condition that generally resolves with more conservative management and the passage of time. In sum, the services at issue were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.  Final Result: Three reviewers determined that the services at issue were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: One reviewer is board certified in physical medicine and rehabilitation with sub-specialty certification in pain management and is actively practicing. Two reviewers are board certified in physical medicine and rehabilitation with sub-specialty certification in sports 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: Upheld

Nature of Statutory Criteria/Case Summary:   An enrollee has requested Provigil (modafinil) for treatment of her condition. Findings:  The physician reviewer found that according to the documentation submitted for review, the medical necessity for the requested medication has not been established. There is a lack of a documentation describing the patients degree of fatigue, consequences of fatigue, contributing factors to the fatigue, previous therapeutic trials, and current status of the MS. Given the lack of information provided for review, modafinil is not medically necessary. 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 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: Experimental/Investigational
Decision: Upheld

A 47-year-old male enrollee has requested use of an interferential neuromuscular stimulator (electrical pulse delivery) for treatment of his chronic back pain. Findings:  Two physician reviewers found that the clinical practice guidelines have not supported the use of electrical stimulation for lumbago. The American College of Environmental Medicine (ACOEM) guidelines state that interferential therapy is not recommended in the setting of chronic low back pain. This view is consistent with the Philadelphia Panel review that reported a lack of evidence demonstrating efficacy of interferential therapy for management of low back pain. Given the status of the scientific data and the standards of modern evidence-based medical practice, the device is of unproven clinical efficacy and therefore remains investigational.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 36-year-old male with a history of polio. He requires use of a left knee ankle foot orthosis (KAFO) for ambulation. The patient reports the KAFO he has been using causes leg irritation and needs to be replaced. The Health Plan has denied authorization for a replacement KAFO on the basis it is not medically necessary. As an alternative, the Health Plan has authorized repair of the patients current KAFO.A newly constructed KAFO is clinically appropriate and necessary for this patient.  It is a superior option to repair of his prior brace and meets community standards for coverage. The patient is likely to achieve better functional results with a new device than with repair of the prior brace. As such, I have determined the requested device is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Overturned

An enrollee has requested authorization and coverage for bronchial thermoplasty. Ideal candidates for bronchial thermoplasty include adults with severe persistent asthma who require regular maintenance medications of inhaled corticosteroids and long-acting beta agonist, with add-on therapies such as leukotriene modifiers, steroids, or biologic agents. These agents reduce inflammation or decrease airways narrowing by relaxing airway smooth muscle but do not prevent the chronic structural changes that occur. Bronchial thermoplasty is an alternative therapy for this patient population. The U.S. Food and Drug Administration (FDA) has approved bronchial thermoplasty for use in this clinical setting. This patients treatment has included treatment in the hospital and emergency department, in addition to standard treatments for asthma including immunotherapy with Nucala. Thus, the requested bronchial thermoplasty is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested services are 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 1 is board certified in internal medicine with subspecialty certifications in pulmonary disease and critical care medicine and is actively practicing. Physician reviewer 2 is board certified in internal medicine with subspecialty certification in pulmonary disease and is actively practicing. Physician reviewer 3 is board certified in internal medicine with subspecialty certification in pulmonary disease and is 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

This patient is a 55-year-old female with a history of non-Hodgkins lymphoma treated with high-dose chemotherapy and stem cell rescue.  Low IgG levels dating back several years were reported by her provider. The patient had recurrent infections following treatment and IVIG therapy was initiated in 2002. Her provider indicates that the frequency and severity of the infections has decreased with continuing IVIG therapy.  It does not appear from the record that IgG levels were monitored regularly. The patient has requested reimbursement for previous IVIG therapy and on-going authorization.  The Health Plan denied the request based upon a determination that the therapy was/is not medically necessary in this clinical setting. Many lymphoma patients never recover in terms of immunoglobulin production even when remission is achieved. The patients baseline IgG level is not known, but was reported as below normal.  An IgG level from 2003 was in the low normal range (882) as expected and may well reflect the IVIG therapy, not the patients baseline value. It may be impossible to know if she has persistent hypogammaglobulinemia and/or if her infections would worsen if she did not receive the IVIG therapy, without placing her at substantial risk. Often patients in this clinical setting continue to receive IVIG if there is evidence of medical benefit. This patient would be in that category given her previous history of frequent infections. The dosage and frequency of her IVIG therapy are medically reasonable. Monitoring of IgG levels is possible, but it is unlikely that a below normal value will result while the patient is receiving IVIG therapy. If monitoring is done, IgG levels should be drawn at the nadir, shortly before the next dose of IVIG is due. It is reasonable to conclude that monthly IVIG therapy is a factor in the patients continued good health.Based upon the information set forth above, I have determined the therapy at issue was/is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

The parents of a 13-year-old male enrollee requested authorization and coverage of speech therapy for the treatment of a complex partial seizure disorder of the right temporal lobe with an audiological rollover phenomenon.  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 services are  medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 51-year-old female enrollee requested authorization and coverage for metal-on-metal hip resurfacing for treatment of rheumatoid arthritis and hip pain.  The health plan has denied this request indicating that the requested procedure is not medically necessary for treatment of the enrollees medical condition.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: Overturned

Nature of Statutory Criteria/Case Summary: The parent of a male enrollee has requested reimbursement for FirstStep Dx Plus (CPT code 81229, chromosomal microarray analysis) testing performed for evaluation of the enrollees autism spectrum disorder. Findings:  The 3 physician reviewers found that chromosome microarray analysis testing has been established as an appropriate first-line genetic testing since 2010 for non-syndromic developmental delay/intellectual disability, as delineated in the American College of Medical Genetics and Genomics (ACMG) practice guidelines. The study by colleagues retrospectively reviewed the medical records of patients who had abnormal chromosomal microarray findings reported per laboratory over a three-year period and quantified the management recommendations made in response to these results. The authors concluded that These results empirically demonstrate the clinical utility of chromosomal microarray by providing evidence that management was directly affected for the majority of patients in our cohort with abnormal chromosomal microarray findings. Based on the support in the medical literature, the testing at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: The 3 reviewers determined that the testing at issue was 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: Physician reviewer number one is board certified in pediatrics and clinical genetics 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 pediatrics and clinical genetics 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 pediatrics and clinical genetics 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 Humira 40mg subcutaneously every 2 weeks. The Health Plan has denied this request indicating that the requested treatment is not medically necessary for treatment of the enrollees psoriasis. A review of the record indicates that the enrollee has been diagnosed with lichen planus, and psoriasis. In a report the enrollees provider noted worsening psoriasis with lesions over the scalp, elbows, and shins. The provider noted Enbrel was discontinued due to hair loss. The enrollee had also been treated with methotrexate, Otezla, Cellcept, and prednisone. The enrollees provider has recommended Humira 40mg/0.8ml subcutaneously every 2 weeks #2 for the enrollee.Humira (adalimumab) is a fully human tumor necrosis factor alpha (TNF-alpha) monoclonal antibody approved for the treatment of rheumatoid arthritis which is also used in treating other conditions, including psoriasis and psoriatic arthritis. Open prospective studies and randomized controlled trials have shown the short-term efficacy of adalimumab in psoriatic arthritis and psoriasis. Adalimumab has been shown to be effective therapy when used either continuously or intermittently at 40 mg subcutaneous injections every other week. In cases resistant to conventional dose, the efficacy of adalimumab can be increased by dose escalation, such as shortening the dosing interval and increasing the amount of medication per single dose. In a multicenter, randomized, double blind, placebo-controlled study, 147 psoriasis patients received adalimumab (40 mg every other week or 40 mg/week) or placebo. After 12 weeks of blinded therapy, patients taking adalimumab could continue their assigned dosages in a 48-week extension trial; patients taking placebo were switched to adalimumab (40 mg every other week). The results demonstrated patients taking adalimumab showed improvement in their psoriasis symptoms. The records documented subjective and objective findings consistent with the diagnosis of psoriasis that was not controlled with trial of topical and systemic treatments. In conclusion, the U.S. Food and Drug Administration (FDA) have approved Humira for the treatment of moderate to severe chronic plaque psoriasis. The approval was based on results of two trials that showed marked improvement in skin condition. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in 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: Upheld

A 54-year-old female enrollee has requested a panniculectomy for treatment of her medical condition.  Findings:  The physician reviewer found that review of the submitted documentation fails to establish the medical necessity of the requested procedure. Panniculectomy involves removal of the lower abdominal skin without the muscle tightening or the supraumbilical skin tightening via periumbilical and lower abdominal incisions of a full abdominoplasty. A panniculectomy would be medically necessary rather than cosmetic in nature if the removed skin has a history of recurrent infections, is necrotic and is so large that it interferes with mobility. The mere presence of a pannus and/or its psychological or physical burden on the patient does not make its removal medically necessary. In this patients case, the documented evidence of a skin condition related to her pannus is prescriptions for nystatin powder and Lotrisone cream and undated photos. In the absence of photos showing a rash after the office visits and recent physical examination denoting the presence of intertrigo, the medical necessity for a panniculectomy has not been established in this clinical setting. Based on the documentation submitted for review and the peer-reviewed literature cited above, the requested procedure is not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 41-year-old female enrollee has requested Provigil for the treatment of her insomnia and borderline narcolepsy. Findings:  The physician reviewer found that this patient has excessive sleepiness which poses a threat to her and others when she is driving. She gets sufficient amounts of sleep during bouts of excessive sleepiness (she reports that she used to sleep up to 90% of the time) and currently the lack of sleep does not appear to be the cause of her daytime sleepiness. She appears to have a sleep disorder, the exact nature of which is not clear. Provigil has been used as an adjunct in chronic debilitating conditions associated with excessive sleepiness including depression, cancer, multiple sclerosis and auto-immune disorders. In this case, the extent of the patients sleepiness is such that treatment is medically necessary due to the potential for injury. Based on the available scientific evidence, Provigil is likely to be effective for treatment of this patients daytime sleepiness. As such, this patient should be treated with Provigil as it is medically necessary.