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

A 41-year-old female enrollee requested authorization and coverage of uterine artery embolization (UAE) for the treatment of an uterine fibroid.  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 upheld the health plans denial on the basis that the requested surgery is not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for tertiary level of care services. As noted in the medical literature, hidradenitis suppurativa can profoundly affect a patients quality of life. Severity is based on clinical appearance as well as impact on quality of life. According to the U.S. and Canadian Hidradenitis Suppurativa Foundations, management is complex and requires balancing medical and surgical treatment options in addition to managing the psychosocial and medical conditions that go along with this disease (Alikhan, et al.). The records provided for review document that this patient has been treated for hidradenitis suppurativa with oral antibiotics, antimicrobial washes, acitretin, Humira, and most recently with Remicade. He has a history of hospitalization for superinfection of his chronic wounds and he required education for wound care. He has been referred to plastic surgery for scarring. Based on these facts, the patients condition is severe, and he meets the criteria for treatment at a higher level of care. He has severe disease that requires surgical, dermatological, pain management, and wound care, which will be best managed and provided at a tertiary care facility. The patient requires higher level of care than a community level provider. Accordingly, the requested tertiary level of care services are 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 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: The patient has requested authorization and coverage for custom orthotic for the left foot. It is well established in the medical documentation that this patient presents with a history of excessive pronation to the left foot, leading to a functional leg length discrepancy with a raised right side. The patient reports ongoing back pain due to an altered gait secondary to overpronation and functional leg length discrepancy. The provider has recommended for the patient be fitted with a  custom orthotic. On review of the medical literature, there is adequate support for use of a custom orthotic in this patients clinical setting. Researchers evaluated the effectiveness of orthotic insoles in patients with mild leg length discrepancy. The authors concluded that, Orthotic insoles significantly improved gait symmetry in the pelvis in the frontal plane and the ankle in the sagittal plane, as well as pain. Thus, an orthotic insert is indicated for this patient to help compensate for a functional leg length discrepancy as recommended by his provider. A customizable orthotic will allow for exacting compensation of a leg length discrepancy. Given these findings, the requested custom orthotic for the left foot is medically necessary for the treatment of this patient. 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 a licensed D.P.M., board certified in podiatric surgery, and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested digital breast tomosynthesis for evaluation of the enrollees medical condition.  Findings: Two physician reviewers found that breast tomosynthesis is a technique that was developed several years ago as a problem solving adjunct to routine mammography.  Applying the same basic concept as computed tomography (CT) scanning, the logic is that by separating the various layers of breast tissue, one can better detect abnormalities.  This has been shown to be most useful in the evaluation of dense breasts.  In this patients case, her breasts were described as heterogeneously dense.  It is specifically those who have dense breasts that can benefit most from tomosynthesis.  The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor.  Additionally, the area of asymmetry was an appropriate indication for breast tomosynthesis.  In sum, digital breast tomosynthesis was likely to have been more effective than other methods of evaluating this patient.Final Result: Two reviewers determined that the services at issue were 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: All three physician reviewers are board certified in diagnostic radiology and are actively practicing. The reviewers are expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested skilled nursing facility services and physical therapy service while receiving skilled nursing facility services for treatment of her medical condition. Findings:  The physician reviewer found that based on the clinical documentation submitted for review, the medical necessity for 24-hour skilled nursing facility care has not been established. In this case, the patient has dementia with baseline impairment of functional mobility. She has shown improvement in self-care and functional mobility from her nadir while in skilled nursing facility. Her improvement has plateaued and she is likely at her new baseline level of function. Moreover, a provider has not recommended additional inpatient skilled nursing facility rehabilitation. The records do not demonstrate a need for skilled nursing facility level physical and occupational therapy. As such, the request for skilled nursing facility services and physical therapy services while receiving skilled nursing facility services has not been established as medically necessary. Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: The reviewer is board certified in physical medicine and rehabilitation and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested a positron emission tomography (PET) scan for evaluation of her medical condition. Findings:  The physician reviewer found that according to the documentation submitted for review, the patient is in remission from her monoblastic sarcoma-acute myeloid leukemia.  She has stable graft versus host disease and no signs or symptoms to warrant a PET scan. A PET scan is not indicated for surveillance and she has no signs or symptoms to suspect any malignancy or recurrence. All told, the requested PET scan is not medically necessary for evaluation of the patients medical condition. Final Result: The reviewer determined that the requested services are not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications:  The reviewer is board certified in medical 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Letermovir 480 mg, 90 tablets for a 90-day supply. The medical records document that this patients clinical picture is consistent with cytomegalovirus (CMV)-related eye disease. The provider noted that the patient required a repeat corneal transplant while receiving valganciclovir prophylaxis, which suggests that valganciclovir may not be adequately suppressing the CMV. However, the recent clinical examination does not show evidence of active CMV infection or inflammation. Although there is evidence to support the use of letermovir for active CMV infection, there is a lack of documentation of active infection (Tsui, et al.). Overall, there is inadequate evidence to support that treatment with letermovir is likely to be more effective than valganciclovir for treatment of this patient. Therefore, the requested Letermovir 480 mg, 90 tablets for a 90-day supply is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings: Three of the three physician reviewers found the requested Letermovir 480 mg, 90 tablets for a 90-day supply is not 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 medication is 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: Physician reviewer 1 is board certified in ophthalmology and is actively practicing. Physician reviewer 2 is board certified in ophthalmology and is actively practicing. Physician reviewer 3 is board certified in ophthalmology 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

The patient is a 40-year-old female who has a long history of obsessive-compulsive disorder (OCD). Though she has been attending twice-weekly cognitive behavioral therapy sessions she has not achieved an adequate response to therapy. The patients medications include Paxil. She wants to have another child and therefore is tapering her medications. The patients provider has recommended the patient attend intensive outpatient cognitive-behavioral therapy. The Health Plan has determined the requested therapy is not medically necessary.Review of the submitted clinical information indicates the patient has been on Paxil, an SSRI. Though SSRIs have been used throughout pregnancy, they are a category C drug (meaning risk is present). The patient should have the option of a medication-free pregnancy. It is likely the patient will obtain good results from intensive cognitive-behavioral therapy alone. Therefore, 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: Urgent Care
Decision: Overturned

A 43-year-old female enrollee has requested emergency services for the treatment of her condition.  Findings:  The physician reviewer found that the patient was suffering from acute onset of abdominal pain of sufficient severity that a prudent layperson would seek immediate medical attention due to concern for potential jeopardy to her health or function.  Her pain was acute and not normal for her.  The constellation of symptoms that the patient was experiencing were consistent with a variety of potentially life-threatening disorders, including pulmonary embolism, acute coronary syndrome, as well as other disorders including acute cholelithiasis, hepatitis, pancreatitis, peptic ulcer disease, urinary tract infection and others.  It was important that the patient was evaluated to ensure that her symptoms were not due to a life-threatening disorder.
Appeal type: Medical Necessity
Decision: Overturned

A 59-year-old female enrollee requested the Flexi-Touch lymphatic pump, suction-assisted lipectomy and double-blind study for medical treatment of her lymphedema.  Findings:  The physician reviewer found that the patient has had CDT, used compression garments, had massage and physical therapy and used exercise for the treatment of lymphedema.  She continues to have recurrent cellulitis and pain with ongoing lymphedema.  The use of Flexi-Touch lymphatic pump (IPC) is a medically appropriate addition to her ongoing treatment regimen.  However, the requested double-blind study using anti-inflammatories is not standard of care and is not medically necessary for the treatment of this patient.  This patient has not failed use of a combined program of CDT, compression garments and IPC.  Furthermore, the surgical intervention is often not permanently effective.  Thus, the surgical procedure of suction-assisted lipectomy is not medically necessary.  All told, the requested Flexi-Touch lymphatic pump is medically indicated for the treatment of this patient.  However, the submitted documentation fails to demonstrate the medical necessity of the requested suction-assisted lipectomy and double-blind study.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 10-year-old male enrollee has requested coverage for applied behavioral analysis (ABA) therapy for six hours per week for treatment of the enrollees autism.  Findings:  The physician reviewer found that ABA has been shown to be effective in treating behaviors associated with autism spectrum disorder (Rogers and Vismara). Treatments based on operant principles of learning are more effective for reducing maladaptive behaviors than alternative treatments.  Warren et al reviewed 34 studies of early intervention in autism. They concluded that studies of Lovaas-based approaches and early intensive behavioral intervention variants and the Early Start Denver Model resulted in some improvement in cognitive performance, language skills, and adaptive behavior skills (Warren, et al). Additional studies have shown that ABA methods continue to result in positive outcomes with individuals with autism and intellectual disability (Grey and Hastings). Evidence-based studies also noted improvement of function in older children with autism spectrum disorders using intense ABA interventions (Granpeesheh, et al). The goals for older children often are to identify and remediate particular deficits. Sallows and Graupner note that although substantial gains are made after one year of ABA therapy when compared to controls, further gains have been noted in subsequent years. This patients behaviors that need to be addressed include maladaptive behaviors of communication, complying with requests, increasing functional life skills as well as social and language skills. All told, ABA therapy is medically necessary for treatment of this patients medical condition at the requested frequency of six hours per week.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for knee surgery and all post-operative follow up appointments for treatment of the enrollees knee pain. Findings:  The physician reviewer found that evidence based medical guidelines and peer reviewed literature support the services at issue in this clinical setting. There is support in the medical literature for the management of recurrent dislocations of the patella in a young individual. Recurrent patellar instability is a common pathology and typically affects younger and more active patients. In this patients case, in order to prevent complete lateral dislocation of the patella, several procedures have been described, both osseous (tibial tubercle osteotomy) and soft tissue procedures, including reconstruction of the medial patellofemoral ligament with cadaver hamstring allograft or patients own hamstring autograft. The medial patellofemoral ligament has been identified as the primary medial stabilizer of the patella. Several techniques have been reported for reconstruction, sometimes in conjunction with other procedures, with the majority of the procedures showing success in correction of the instability consisting of recurrent patellar dislocations. However, medial patellofemoral ligament reconstruction is not free of complications, and this was the fourth surgical procedure and a second attempt at medial patellofemoral ligament reconstruction.  As such, the procedure was not only medically necessary but also necessary to perform at a tertiary institution by a provider who is experienced in revision surgery. On the basis of the foregoing, the knee surgery and all post-operative follow up appointments were medically necessary for 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 orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 53-year-old female enrollee has requested transcranial magnetic stimulation therapy for treatment of her depression. Findings:  Two physician reviewers found that to date, the Food and Drug Administration (FDA) has not approved TMS as a therapeutic device for any neuropsychiatric disorder, including depression. There is a paucity of evidence in the form of randomized clinical trials establishing the safety and efficacy of TMS for the treatment of depression. The scientific data does not gauge relief of patients symptoms on the Beck Depression Inventory or Hamilton Depression Rating Scale. Moreover, none of the published studies were truly double blind and were based on small samples over short periods of time. In addition, TMS has not been shown to be any more effective than pharmacological intervention for patients who have failed to improve after multiple medication failures. Research is still needed to ascertain the long-term (greater than two-years) safety and efficacy of TMS therapy in the treatment of depression. For these reasons, TMS remains investigational.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a 10-month-old female enrollee has requested physical therapy for treatment of the enrollees Down syndrome.  Findings:  The physician reviewer found that children with Down syndrome may have medical vulnerabilities and congenital abnormalities that occur in greater frequency. As a result, the prevention of secondary disability is important. The central hypotonia slows the acquisition of gross motor skills.  Ligamentous laxity with hypotonia complicates the ability to acquire appropriate gross motor skills. Physical therapy is needed for continued improvement in gross-motor skills acquisition. The long-term benefit of physical therapy is that it helps prevent compensatory movement patterns that individuals with Down syndrome are prone to developing. This can lead to orthopedic and functional problems if not corrected. Physical therapy is medically necessary for individuals with gross motor delays greater than 25%. This patient had minimal gross motor delays during her most recent physical therapy evaluation. As such, she is likely to continue to benefit from early intervention services. However, a physical therapy evaluation is recommended in 4 months to evaluate the need for PT services through the Health Plan if gross motor delays are greater than 25%.
Appeal type: Medical Necessity
Decision: Upheld

A 52-year-old male enrollee has requested Benicar for the treatment of his hypertension. Findings:  The physician reviewer found that there is no objective clinical documentation to suggest a true allergy to an ACE inhibitor. Overall, Accupril is well-tolerated. Despite the patients vague complaints of side effects to two other medications, there is no clear reason from a medical perspective to not consider a formulary medication in this case.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Xiaflex for treatment of his medical condition. Findings:  The physician reviewer found that Peyronies disease is caused by scar tissue, called plaque, which forms along the length of the penis in the corpora cavernosa.  This plaque is not visible, and depending on the severity of the condition, this condition can cause penile curvature with erection.  Potential treatments for Peyronies disease include surgery, minimally invasive treatment options, and medications.  The results for most previously available medications and minimally invasive therapies have been inconsistent or lacked empirical support for effectiveness.  The current medical evidence supports Xiaflex in this clinical setting.  All told, Xiaflex is medically indicated for the treatment of this patient. 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 urology 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 44-year-old female enrollee has requested Mirena IUD and related services for treatment of her menorrhagia.   Findings:  Two physician reviewers found that the submitted clinical evidence does not demonstrate the patient was experiencing abnormal bleeding at the time of the Mirena IUD insertion. A notation indicates that the patient had no complaints. Additionally, there was a notation wants IUD has used ParaGard IUD for 2-3 years, had removed for heavy periods. It seems that the insertion of the IUD was for contraception. Furthermore, it is the standard of practice to attempt hormonal treatment (e.g. progesterone) for a limited time to treat a 44-year-old patient with abnormal bleeding. If that does not help, an endometrial biopsy is considered essential to rule out endometrial hyperplasia or carcinoma. A sonogram to rule out ovarian pathology is often considered. From the information presented, none of these procedures were instituted. A Mirena IUD is not considered as initial therapy for abnormal uterine bleeding. Indeed, it remains unproven for this indication at the present time.