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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for an oral device and associated services. The Health Plan has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees sleep apnea. Findings: In this case, the patients clinical presentation indicates a diagnosis of OSA and he is reported to be CPAP intolerant. The medical literature indicates that oral appliance therapy is an acceptable second line therapy option for CPAP intolerant patients with OSA (Epstein et al). Current practice guidelines from the American Academy of Sleep Medicine and the American Academy of Dental Sleep Medicine support the use of oral appliance therapy in patients with mild or moderate OSA who are intolerant of or decline CPAP. The patient has been referred to a dental provider for an oral appliance. Accordingly, the potential provision of an oral appliance in this case would be within the currently accepted standards of medical practice for the treatment of this patients OSA. In this patients case, the request for an oral appliance has been demonstrated as medically necessary. Additionally, the patient would require a dental examination for the oral appliance. As such a consultation with a dental provider would be indicated to determine if the patient has an adequate dental status for provision of an oral appliance. However, with regards to diagnostic imaging, the request is premature at this time. Not all dental providers perform x-rays in this setting. Once the patient is evaluated by a dental provider, the provider can then determine if x-rays are clinically indicated. Therefore, with regards to diagnostic imaging, this diagnostic procedure has not been demonstrated as medically necessary at this time.Final Result: The reviewer determined that a portion of the requested services are medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be partially overturned.Credentials/Qualifications: The reviewer is board certified in neurology with sub-specialty certification in sleep 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for transcatheter mitral valve repair and transesophageal echocardiography.Findings:  Three physician reviewers found that this patient has significant symptomatic congestive heart failure secondary to mitral prolapse which is anatomically favorable for either mitral repair surgery or percutaneous mitral clip therapy. Normally, mitral surgery with valve repair would be the most reasonable standard therapy for this condition. However, the enrollee has significant comorbidities which would make surgery much higher risk for this patient. Specifically, the enrollee is diagnosed with a form of hyper-IgE syndrome, for which they take both immunosuppressive and chronic steroid therapy. This syndrome and its treatment regimen predisposes the enrollee to a higher risk of postoperative surgical issues, including both bacterial infections and poor wound healing. Given the increased risk of postoperative complications, along with the known efficacy of the percutaneous procedure, percutaneous mitral clip therapy in specific clinical instances can provide an improved risk/benefit profile for treatment of this condition as a reasonable alternative to a higher risk open heart surgery procedure. In sum, transcatheter mitral valve repair and transesophageal echocardiography are likely to be superior over other treatment options. 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 reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in cardiovascular disease and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 52-year-old female enrollee has requested electron beam computerized tomography (EBCT) coronary artery calcium (CAC) scoring for an evaluation of her coronary arteries. Findings:  Three physician reviewers found that EBCT for CAC scoring is not an accepted screening or confirmatory test for the diagnosis of coronary artery disease in this patient subset. It is not a medically acceptable replacement for other conventional screening tests within the standard of care such as treadmill stress testing.
Appeal type: Medical Necessity
Decision: Upheld

A 59-year-old female enrollee has requested universal endoscopic laser discectomy for treatment of her low back pain.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services in this patients case.  The current medical evidence does not support the requested universal endoscopic laser discectomy in this clinical setting.  Gibson and Waddell conducted a review to assess the effects of surgical intervention for the treatment of lumbar disc prolapse.  The authors concluded that there is a need for high-quality, randomized, clinical trials to determine whether there is a role for laser discectomy.  Singh and colleagues performed a systematic review of the literature to evaluate the efficacy of percutaneous laser discectomy for patients with radicular pain secondary to disc herniation.  The authors noted that there is a lack of randomized clinical trials.  In sum, there is an absence of high-quality, randomized, clinical studies demonstrating the safety and efficacy of the requested services.  All told, universal endoscopic laser discectomy is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting authorization and coverage for Xelajanz (tofacitinib), 5 mg tablet. The enrollee has alopecia areata. She was diagnosed at age nine. At an office visit with her dermatologist, she reported she had lost almost 80 percent of her hair. She has received Kenalog injections, Rogaine, and topical medications. Her occipital and temporal areas are the most difficult to regrow. The recommendation was for treatment with Xeljanz (tofacitinib). The provider reports that, due to the lack of alternatives that are safe and effective, and the trial and failure of steroid injections, treatment with tofacitinib is being requested. This enrollee has tried and failed conservative therapy. Alopecia areata is not a cosmetic disorder. It is an autoimmune disorder that affects the hair or nails and glandular structures. This is a disease process. It is associated with depression, anxiety and social isolation, which are significant psychosocial conditions. Xeljanz has been found safe, effective and durable for the treatment of alopecia areata. Literature reports alopecia areata affects people of all ages. There is currently no cure, and a highly effective therapy for severe disease has been elusive. A clinical trial of tofacitinib for the treatment of severe alopecia areata showed, of the 66 subjects treated, 64 percent of subjects responded to treatment.Final Result: The reviewer determined that the requested service is medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 61-year-old male enrollee has requested  for Lumigan, 7.0 ml (or 7.5 ml) per month for treatment of the enrollees glaucoma.  Findings:  The physician reviewer found that one 2.5 ml bottle of Lumigan drops will last the typical patient one month, with once-daily usage. If it does not last for an entire month, then one of three conditions is likely to be occurring: The medication is being administered more frequently than prescribed;The medication is being wasted due to improper administration; orThe bottle was not properly filled by the manufacturer.Additionally, with all of the discussion that has ensued over the quantity of medication needed on a monthly basis, it does not appear likely that the patient is using the medication more often than prescribed. Therefore, the most logical explanation is that the patient is having difficulty with administration, and is inadvertently wasting a quantity of the medication each month.
Appeal type: Medical Necessity
Decision: Upheld

The mother of a four-year-old male enrollee requested authorization and coverage of speech therapy. The Health Plan denied the request indicating that the requested therapy is not medically necessary for treatment of the enrollees speech impairment.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested therapy is not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

The patient has requested reimbursement for residential treatment center (RTC) and reimbursement and prospective authorization and coverage for partial hospitalization program (PHP) services. Per the American Society of Addiction Medicine (ASAM) criteria, this patient met Level 3.5 criteria for clinically managed high-intensity residential services, and Level 2.5 partial hospitalization services. ASAM criteria focuses on six dimensions to determine the appropriate level of care, which includes: (1) intoxication and withdrawal potential; (2) biomedical conditions; (3) emotional, behavioral and cognitive conditions; (4) readiness to change; (5) relapse, continued use, or continued problem potential; and (6) recovery environment. The patients anxiety and depression continue to be problematic, but are appropriate for the PHP setting. PHP services are comprised on 20 or more hours per week and is a step-down from the 24-hour care that is provided with Level 3.5 RTC services. Given these findings, the RTC level of care services, and PHP level of care services were and are medically necessary for treatment of this patient. Final Result: The reviewer determined that the services at issue 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 psychiatry with expertise in addiction 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:   An enrollee has requested a transcranial magnetic stimulation (Spring TMS) device for the treatment of her medical condition. Findings:  Three physician reviewers found that review of the submitted documentation and relevant literature supports the use of the Spring TMS device in this clinical setting. The Spring TMS device is U.S. Food and Drug Administration (FDA) approved treatment for chronic migraine. The study by Weatherall and colleagues evaluated patient response to the Spring TMS device. The authors found that 73% of patients prescribed the device reported partial or complete pain relief, 53% reported a reduction in the number of headache days, 63% reported a reduction in non-pain migraine symptoms, and 17% reported improved sleep quality. These improvements continued throughout and beyond the three-month study period. Given the support in the peer-reviewed literature, the Spring TMS device was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.  Final Result: Three reviewers determined that the device at issue was 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:  All three reviewers are board certified in neurology and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a five-year-old female is requesting speech therapy for the treatment of the enrollee's pervasive developmental disorder (PDD), autism spectrum. Findings:  The physician reviewer found that virtually all medical studies of autistic spectrum children have established the need for speech therapy intervention. Multiple studies have concluded the need for speech therapy to be initiated at time of diagnosis and to continue until the child improves speech competency to an age-specific level.  In this child, the need for speech therapy is medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld

A 60-year-old female enrollee has requested intravenous immune globulin therapy (IVIG) for the treatment of her multiple sclerosis. Findings:  Two physician reviewers found that this patient has been on Copaxone, Betaseron, Novantrone, steroids and Cytoxan. She has also been on Baclofen, Aricept and Namenda. The patient has had a course of IVIG with some reported benefit. Although IVIG therapy has been shown to have some benefit in multiple sclerosis in a number of small trials, there is a lack of data regarding combination therapy with Copaxone. While there is supportive data regarding IVIG monotherapy, the recommended combination therapy cannot be recommended at this time due to a lack of data and potential risks. The therapy at issue is not likely to more efficacious for this patient than alternative treatment options.
Appeal type: Medical Necessity
Decision: Upheld

A 61-year-old male enrollee has requested full body scans for an evaluation of his prostate cancer. Findings:  The physician reviewer found that whole body scans, either CT or MRI, have been shown to not be efficacious in screening for cancer.  Screening whole body scans have shown no clear health benefit.  In addition, CT scans utilized for whole body scans expose patients to unnecessary radiation.  When there is evidence of recurrent or metastatic disease, individual imaging tests are reasonably ordered pertinent to the patients specific symptoms (e.g., a bone scan for persistent bone pain).  The American College of Radiology does not support the use of whole body screening exams.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Xyosted 75 mg/0.5 mL autoinjector. A study reported that Xyosted is safe and effective for the treatment of patients with hypogonadism. Moreover, the U.S. Food and Drug Administration (FDA) has approved Xyosted for this indication. Studies have demonstrated that Xyosted is less painful than intramuscular injection therapy. Thus, Xyosted is a viable treatment option for patients who are unable to tolerate intramuscular injections. This patient presents with symptomatic hypogonadism. Based on the available documentation, the patient requires treatment with testosterone replacement therapy. Preparing conventional depot testosterone for self-injection requires patients to withdraw the appropriate prescribed dosage into a syringe prior to delivery. This patient has a history of intravenous drug use. Preparing testosterone for self-injection can be a trigger for patients with a history of intravenous drug use. The use of Xyosted autoinjector bypasses that procedure. All told, the requested Xyosted 75 mg/0.5 mL autoinjector is medically necessary for 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: Medical Necessity
Decision: Upheld

A 57-year-old male enrollee has requested an electric scooter for the treatment of his sternal, knee and back pain. Findings:  The physician reviewer found that this patient does not meet generally accepted medical necessity criteria (i.e., Medicare guidelines) for an electric scooter (or Power Mobility Device). This patient does not have a mobility related deficit that affects his ability to ambulate and complete MRADLs within his home in a reasonable time. He is at minimal risk of falls, which can be reduced with the use of a four-wheeled walker. The fact that this patient needs assistance with lower body dressing does not appear to be due to a mobility impairment. The patient was noted to have pain but was not observed to have shortness of breath during his most recent evaluation. All told, there is inadequate evidence to support the use of an electric scooter in this particular setting.
Appeal type: Medical Necessity
Decision: Upheld

The enrollee is requesting authorization and coverage for residential treatment center (RTC) level of care. The Level of Care Utilization System (LOCUS), developed by the American Association of Community Psychiatrists, is a level of care assessment tool widely used by clinicians throughout the country to support accurate level of care recommendations. The six dimensions of LOCUS include risk of harm, functional status, comorbidity, recovery environment, level of support, and treatment and recovery history. The enrollees composite LOCUS score correlates with Level IV, medically monitored non-residential services.Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for magnetic resonance imaging (MRI) of the pelvis and abdomen. Researchers note that ultrasound for pelvic pain `provides detailed information of the pelvis, is relatively inexpensive, widely available, and avoids ionizing radiation,` and that MRI is reserved for specific indications.  Researchers note that MRI may play a role in further evaluation of some adnexal masses already found on ultrasound (for example, differentiating a pedunculated uterine fibroid from an ovarian mass).Here, this patient has multiple pain conditions that are likely functional in origin, and an MRI will not help in diagnosing those conditions. A recent normal CT scan rules out the need for further evaluation of adnexal masses. This patient has no other indications for which an MRI might be necessary. Therefore, the requested MRIs of the pelvis and abdomen are not 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 obstetrics and gynecology 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 semi-electric hospital bed with a lift device (trapeze) and over bed table for treatment of her medical condition.  Findings: The physician reviewer found that the semi-electric hospital bed with a lift device (trapeze) and over bed table was not medically necessary for treatment of this patients medical condition status post knee surgery. The documentation does not indicate that the patient has a medical condition which required positioning of the body in positions not feasible with an ordinary bed. In addition, the patient did not require the head of the bed elevated for medical reasons such as problems with aspiration or congestive heart failure. Further, the documentation does not demonstrate that the patient required traction equipment, an immediate need for a change in body position, or frequent changes in body position. Moreover, there is a lack of evidence that this patient had a pressure ulcer that required specialized bedding. For these reasons, the documentation does not support the medical necessity of the semi-electric hospital bed with a lift device (trapeze) and over bed table.  Final Result: The reviewer determined that the equipment at issue was not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The physician 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.