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

Nature of Statutory Criteria/ Case Summary:  The enrollee requested coverage for hydroquinone cream 4%. The patient was seen for a rash on her legs, which was thought to be due to mosquito bites. Physical examination showed multiple papular eruptions throughout the legs. She was given a prescription for hydroxyzine. The notes otherwise do not mention hydroquinone, other than it was prescribed for a rash and nonspecific skin eruption. Hydroquinone is a cosmetic bleaching agent. It is not medically necessary for any skin condition. Furthermore, there is minimal provided information in the clinic notes regarding the use of this medication. Therefore, the requested medication, hydroquinone cream 4%, is not medically necessary to treat the patients medical condition. 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 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

The parent of a 16-year-old male enrollee requested authorization and coverage of an Otto Bock C-Leg (C-Leg) prosthesis for treatment of below the knee amputation as a result of Ewing Sarcoma.  The health plan denied the enrollees request indicating that the requested prosthesis 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 equipment is not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested acupuncture for treatment of her neck, shoulder and back pain.  The physician review found that review of the submitted documentation and relevant literature demonstrates the medical necessity of the requested services. According to the documentation submitted for review, the patient previously underwent acupuncture sessions which were documented as beneficial. Gains were described as symptom reduction, medication intake reduction and range of motion improvement. According to the patient, the benefits obtained from acupuncture were superior to benefits obtained with physical therapy, nerve blocks and epidurals. In regards to the patients neck complains, based on peer reviewed literature acupuncture is superior to conventional massage, dry needling of local myofascial trigger points, and sham laser acupuncture, for improving active range of motion, pain, shortening disease duration time and improving functional ability in patients with chronic neck pain, especially in patients with myofascial pain syndrome. In regards to lower back complains, acupuncture is recommended as an option for chronic low back pain using a short course of treatment in conjunction with other interventions. Acupuncture has been found to be more effective than no treatment for short-term pain relief in chronic low back pain. Regarding the patients shoulder condition, the peer-review literature  supports acupuncture as appropiate as it offered good clinical results in diminishing symptoms, shortening disease duration time and improving functional ability, even in long-lasting disease (up to 10 years). Also acupuncture has been found to be an effective long-term treatment for patients with shoulder pain (from soft tissues lesions). Given the patients continued symptomatology which already benefitted with prior acupuncture care and based on peer-review literature, additional acupuncture care is medically necessary. 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 acupuncture 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 gene tests (MyRisk panel) for evaluation of the enrollees risk for cancer. Findings: Two physician reviewers found that this patient has no personal history of cancer, and with no family history suggestive of hereditary cancer syndrome is not eligible for panel gene testing. In keeping with National Comprehensive Cancer Network (NCCN) guidelines, patients with suggestive personal or family history of a single cancer syndrome should only be tested for the syndrome in question. Panel or multi-gene testing is not appropriate in similar patients. There is a lack of prospective randomized controlled studies showing improved outcomes correlating the results obtained from similar tests with improved overall survival, progression free survival, or quality of life. Further, these tests have yet to be correlated with improved health outcomes. Thus, the gene tests (MyRisk panel) rendered is not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: Two reviewers determined that the testing at issue is not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: All three physician reviewers are board certified in internal medicine with sub-specialty certification in medical oncology 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 an 18-year-old woman with a history of myofascial pain and masticatory dysfunction with chronic progressive degenerative changes in both temporomandibular joints. The patient has a dysfunctional dental malocclusion with asymptomatic class II deep bite deformity. The patient experiences pain relief and improved function of muscles of mastication when the dental malocclusion is neutralized with a dental occlusional splint. A request has been made for orthognathic surgery. The Health Plan has denied the request indicating that orthognathic surgery is not medically indicated.The patients pain and disability are directly related to her dysfunctional dental malocclusion. The submitted records document confirmed degenerative joint disease in both temporomandibular joints. In addition, the patient experiences relief of her symptoms when the malocclusion is neutralized. The patient has a severe dental malocclusion, which cannot be adequately corrected with orthodontics alone. Given these factors, orthognathic surgery is medically appropriate and indicated.Based upon the information set forth above, I have determined that the requested procedure is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for acupuncture services two times a week. Findings:  The physician reviewer found that Yang and colleagues concluded that acupuncture, acupressure, and cupping could be efficacious in treating the pain and disability associated with chronic neck and low back pain. Trinh and colleagues reported that there was moderate-quality evidence indicating that acupuncture is more effective than inactive treatment for relieving pain at short-term follow-up, and that those who received acupuncture reported less pain and disability at short-term follow-up than those on a wait-list. Vickers and colleagues noted that acupuncture treatment is a reasonable option for a patient with chronic pain. In this case, the patient has seen several providers and reports constant pain throughout his body, joints, and muscles. He reports that for a couple of days following each acupuncture treatment, he is able to function without constant pain. Given current medical literature and the documented benefits from prior acupuncture treatments in this case, the requested services are medically indicated. Therefore, acupuncture services two times a week are medically necessary for the 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 chiropractic medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement and prospective authorization and coverage for 25 hours per week of direct applied behavioral analysis (ABA) therapy and six hours per month of supervision and treatment training provided for treatment of the autism.  Findings:  The physician reviewer found that in this case, the patient demonstrates significant delays in social skills and adaptive skillsets as measured across multiple domains. The patient needs a high level of support to transition appropriately and interact with peers. The patient also requires ABA supports to address flight risk concerns. Several studies have recommended 25 or more hours of weekly ABA to ensure optimal outcomes. Given the medical necessity of ABA for children with autism, coupled with the clinical documentation submitted for review, the request for 25 hours per week of direct ABA therapy along with six hours per month of supervision and treatment training provided at a summer camp setting were and are medically necessary for treatment of the patients medical condition. 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 pediatrics with sub-specialty certification in developmental-behavioral 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: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a stress echocardiogram. Findings:  The physician reviewer found that Stress echocardiography is appropriate for patients with symptoms suggesting the possibility of coronary ischemia. Stress echocardiography may also aid in evaluating additional possible causes of exertional dyspnea, such as left ventricular dysfunction, occult valvular disease and diastolic dysfunction. In this case, the patient has multiple coronary risk factors and reports significant exertional dyspnea, suggesting possible ischemia. The provider has recommended further evaluation with stress testing, which is considered standard practice. Therefore, a stress echocardiogram is medically necessary for the evaluation of this patient. Final Result: The reviewer determined that the requested service 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 internal medicine with sub-specialty certification in cardiovascular disease 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 reimbursement for OrthoPak osteogenesis stimulator (bone growth stimulator).Findings:  The physician reviewer found that there is support in the literature for the device at issue in this clinical setting. During the last few decades, electrical current stimulation has gone from an investigational modality to an accepted method of treatment to assist with bone healing. Electrical stimulation is based on the premise that mechanical stress applied to bone results in the generation of electric potentials. The studies have shown that the generation of an electrical field at the fracture site should have the ability to enhance bone formation. In this patients case, the provider noted that three months post-surgery, there was no union of the first tarsometatarsal fusion.  A bone growth stimulator was utilized at that time with good outcome.  The other option would have been additional surgery with bone grafting and plating. As such, the bone growth stimulator was effective in treating this patient. Final Result: The reviewer determined that the device at issue was 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: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for a wearable cardioverter defibrillator rental. Based on the records provided, this patient sustained a ventricular fibrillation arrest after coronary artery bypass surgery. In the circumstance of ventricular fibrillation that is not in the setting of an acute coronary ischemic event within the previous 24-48 hours and not in the setting of any documented transient reversible cause, placement of an implantable defibrillator is considered the standard of care. Thus, a wearable external defibrillator would be indicated only if accepted criteria for an implantable defibrillator were met and an implantable defibrillator could not be placed, needed to be significantly delayed or required explantation. There is no documentation supporting that an implantable defibrillator needed to be delayed or could not be placed. Given these findings, wearable cardioverter defibrillator rental was not medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the device at issue was not and 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 certification in cardiovascular disease 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

A 47-year-old male enrollee has requested for the transcranial magnetic stimulation (TMS) therapy for treatment of his depression. Findings:  The physician reviewer found that the Mayo Clinic has stated It's not yet known if transcranial magnetic stimulation can be used to treat depression for the long term, or whether you can have periodic maintenance treatments to prevent depression symptoms from returning. The effectiveness of transcranial magnetic stimulation may improve as researchers learn more about techniques, the number of stimulations required and the best sites on the brain to stimulate. TMS is certainly indicated for the treatment of acute phase unilateral depression.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested artificial cervical total disc arthroplasty for treatment of his medical condition.  Findings:  Two physician reviewers found that the request for artificial cervical total disc arthroplasty is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. There is sufficient support for the requested services in this clinical setting. Davis and colleagues evaluated the safety and effectiveness of two-level total disc replacement using a Mobi-C cervical artificial disc at 48 month follow-up. The authors concluded that total disc replacement is a safe, effective, and statistically superior alternative to anterior cervical discectomy and fusion for the treatment of degenerative disc disease at two contiguous cervical levels. In addition, Rao and colleagues performed randomized controlled trials with a total of 4,061 patients. The results of the meta-analysis indicated that cervical disc arthroplasty was superior to anterior cervical discectomy and fusion with better neurological success, greater motion preservation at the operated level, fewer secondary surgical procedures, and lower rates of adverse events. In light of the support in the peer-reviewed literature, the request for artificial cervical total disc arthroplasty at two levels is supported as superior to anterior cervical discectomy and fusion.  Final Result: Two 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: All three reviewers are board certified in orthopedic surgery 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: Experimental/Investigational
Decision: Upheld

A 60-year-old female enrollee has requested the medications Avastin and/or Tarceva for treatment of her liver cancer.   Findings:  Three physician reviewers found that there are few standard treatment options for this disease and outcomes are generally poor. Nexavar (sorafenib) has been shown to improve outcomes in patients with unresectable or metastatic hepatocellular carcinoma (Llovet, et al.). In addition, local therapies, including chemo-embolization, have been found to be of some benefit. There is a lack of data demonstrating that either Tarceva or Avastin alone result in a better outcome in this setting than the standard agent Nexavar. The studies performed to date are phase II trials and do not include comparison to other therapies. The combination of Tarceva and Avastin for patients with advanced hepatocellular carcinoma has been reported in a single phase II study (Thomas, et al.). This study did show some promising results, with a 25% objective response rate and a median progression free survival of 39 weeks. However, given the absence of any other compelling data supporting this regimen, these results alone are not sufficient to establish the superiority of the combination of Tarceva and Avastin over standard therapies for treatment of advanced hepatocellular carcinoma.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for a Tepezza 10 mg/kg infusion and authorization and coverage for Tepezza 20 mg/kg infusions every 3 weeks for seven (7) additional doses.Findings: Three out of three physician reviewers found that the Tepezza 10 mg/kg infusion at issue and the requested Tepezza 20 mg/kg infusions every 3 weeks for seven (7) additional doses were, and are, likely to be more beneficial than any other available standard treatments for the patients medical condition.Thyroid eye disease is an autoimmune disorder that is associated with hyperthyroidism and causes substantial morbidity, including orbital disfigurement, double vision, and visual loss. Management is guided by its activity and severity status, and treatment options until recently have been limited to smoking cessation, control of hyperthyroidism, local eye measures, glucocorticoids, selenium, orbital radiotherapy, and surgery. Newer targeted biologic therapies have recently become available which have shown promise, including Tepezza (teprotumumab), an IGF-1 receptor antagonist. Tepezza appears to substantially reduce proptosis associated with Graves Ophthalmopathy. This medication has demonstrated impressive reductions in disease activity and severity of Graves Ophthalmopathy. Thus, the Tepezza 10 mg/kg infusion at issue was likely to have been more beneficial than any other available standard treatments for the patients medical condition. Furthermore, the requested Tepezza 20 mg/kg infusions every 3 weeks for seven (7) additional doses are likely to be more beneficial than any other available standard treatments for the patients medical condition.Final Result: The reviewer determined that the services at issue and requested services were, and are, likely to be more beneficial than any other available standard treatments for the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in internal medicine, with subspecialty certification in endocrinology, diabetes and metabolism, 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: Medical Necessity
Decision: Upheld

A 52-year-old male enrollee has requested partial hospitalization program (PHP) services for treatment of his  alcohol dependence.  Findings:  The physician reviewer found that based on the medical records provided for review, this patient was stable and not demonstrating signs of withdrawal. He has hypertension but this condition is reportedly controlled with anti-hypertensive medications. During treatment, the patient was motivated, participated in treatment, and demonstrated readiness to change. There is some relapse potential due to his job and home environments, but this does not require treatment at the PHP level of care. The patient had a supportive home environment and he could have been safely treated at a lower level of care such intensive outpatient or an office based setting. As such, this patient does not meet medical necessity criteria for PHP services.