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

Nature of Statutory Criteria/Case Summary: An enrollee has requested a Permobil F5 Group 4 power chair for treatment of his medical condition. The submitted documentation establishes the medical necessity of the requested Permobil F5 Group 4 power chair. There is sufficient support in the medical literature for the requested equipment. According to researchers, The benefits of power-mobility devices are reported to include improved quality of life, an increased sense of freedom and improved self-esteem. Power mobility can benefit specific individuals. Determination of who will benefit is a matter of clinical judgment more than of adherence to criteria defined by the literature. In this case, the patient has a profound mobility deficit that requires an appropriately fitted power wheelchair. With a power wheelchair he is able to achieve functional mobility. The wheelchair must be properly fitted to reduce risk of pressure ulcers and other complications of spending long periods in a single position. Researchers performed a systematic review and concluded that standing 60 minutes daily can improve range of motion and bone mineral density. Thus, the requested equipment is indicated for this patient to achieve functional mobility and to reduce complications of quadriplegia. Therefore, based on the clinical documentation submitted, the Permobil F5 Group 4 power chair is medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the requested equipment 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 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.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for facial feminization surgery is medically necessary for treatment of this patient. Facial feminization surgery is medically necessary for many transgender women to help alleviate the psychological distress they experience related to gender dysphoria. The World Professional Association for Transgender Health (WPATH) supports facial feminization surgery 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. For this patient with gender dysphoria, her providers have planned for her to undergo facial feminization procedures to better align her physical appearance and gender identity. Given this support, the requested facial feminization surgery is medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in psychiatry with subspecialty certification 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: Experimental/Investigational
Decision: Upheld

An enrollees parent has requested reimbursement and prospective authorization and coverage for food-tolerance induction program (TIP) with oral immunotherapy. Food oral immunotherapy may promote desensitization to food protein but it is has been associated with increased risk of adverse reactions. Oral immunotherapy with rush phase or build-up phase may improve peanut tolerance, but may also induce moderate-to-severe allergic response. This patient was started in food TIP due to cows milk and peanut allergy. However, the American Academy of Allergy Asthma and Immunology (AAAAI) guidelines do not recommend oral immunotherapy in this patients clinical setting due to uncertainty whether therapeutic benefit outweighs risk of treatment. Overall, there is a lack of consensus on the optimal protocol for oral immunotherapy as well as concern regarding the risks for anaphylaxis and other adverse reactions. Given these findings, the food TIP with oral immunotherapy was not and is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a six-month-old male enrollee has requested authorization and coverage for in-home physical therapy for treatment of the enrollees Hirschsprungs disease and intracranial hemorrhage.  Findings:  The physician reviewer found that in an effort to reduce neurological dysfunction, it is clear from the scientific data that PT is instrumental following an acquired brain injury (ABI) and remains essential for a patient to achieve full rehabilitation potential. In summary, PT is essential to promote recovery to the greatest degree possible in patients with ABI.
Appeal type: Experimental/Investigational
Decision: Overturned

The parent of a 10-year-old male enrollee has requested reimbursement for brain imaging, tomographic (SPECT) scans (2) for an evaluation of the enrollees attention deficit/hyperactivity disorder, oppositional defiant disorder and mood disorder, not otherwise specified. Findings:  Two physician reviewers found that the diagnostic procedures at issue were medically indicated for this patient. Sophisticated functional neuroimaging studies can provide additional diagnostic clues to complex neurochemical disorders in the central nervous system. Specifically, SPECT scanning can identify functional changes in dopamine transporter kinetic indices in midbrain, basal ganglia and cortex to help sort out what may be the best therapeutic approach for difficult cases such as this.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a chest computed tomography (CT) scan for evaluation of the enrollees multiple myeloma. Findings:  The physician reviewer found that the presence of an extrapleural mass in this patient with multiple myeloma is of significant concern and the possibility of a neoplastic disorder has to be ruled out. A follow-up CT of the chest is indicated and the CT will serve as a baseline for comparison. The requested CT of the chest will help analyze the adjacent ribs, pleura and lung to assess for any change in size. An increase in size or bone destruction will result in a change in treatment. Moreover, plain film imaging will not provide the same level of detail provided with three-dimensional (3D) CT views. Based upon the records, the requested chest CT scan in this patient is appropriate and medically necessary for evaluation of his multiple myeloma. Final Result: The reviewer determined that the requested service is medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in diagnostic radiology 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

Findings:  The physician reviewer found that An enrollee has requested authorization and coverage for nerve block injections. Occipital neuralgia is a debilitating pain condition that can be refractory to many treatment modalities. Conservative treatment options include medications, occipital nerve blocks, and surgical intervention for refractory patients. This patient has a history of chronic migraine and occipital neuralgia. The provider noted that the patient has experienced significant relief with occipital nerve blocks and is likely to have benefit with repeat blocks. Ebied and colleagues reported that, Occipital nerve block, consisting of a local anesthetic and/or corticosteroid, has been shown to be an effective treatment for the management of migraines. Similarly, Juskys and Sustickas concluded that, Occipital nerve block with a local anaesthetic and corticosteroids provides a safe, simple, and effective treatment method for the patient with medically-refractory occipital neuralgia. Given this support, the requested nerve block injections are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Findings: Two of the three physician reviewers found the requested nerve block injections are 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.
Appeal type: Medical Necessity
Decision: Upheld

A 30-year-old female enrollee requested authorization and coverage of gastric bypass surgery for the treatment of morbid obesity.  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: Experimental/Investigational
Decision: Overturned

 A fifty-nine year-old female with a history of metastatic leiomyosarcoma is requesting authorization to participate in a Phase II clinical trial of ET-743 (Yondelis).  The patient has progressed on several regimens and currently has progressive disease.  Reviewers Findings:Two of the three reviewing physicians found that the patient has exhausted standard treatment; given previous trials of Yondelis, it seems the patients participation in the proposed trial is a rationale approach to the management of the malignancy.  The third physician found that although the patient is no longer a surgical candidate to palliate her disease, it does not appear she has had an adequate trial of Doxil chemotherapy to determine whether the patient would benefit from treatment.  The reviewers found that the health plan denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

A 52-year-old female requested authorization and coverage of sclerotherapy. The Health Plan denied the request indicating that the requested therapy is not medically necessary for treatment of the enrollees varicose veins.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: Medical Necessity
Decision: Upheld

A 37-year-old female enrollee has requested for an MRI of the leg, bilateral for evaluation of her left lower extremity pain and swelling. Findings:  The physician reviewer found that the medical records indicate that the patient has cord-like varices of the left lower extremity.  She has complaints of a swollen left knee.  MRI is not medically indicated under these circumstances.
Appeal type: Medical Necessity
Decision: Upheld

A 53-year-old female enrollee has requested at least 40 chiropractic visits per year for treatment of her cervical and lumbar spine injuries.  Findings:  The physician reviewer found that review of the submitted documentation fails to demonstrate the medical necessity of the requested therapy. The treating chiropractic office notes lack the necessary clinical documentation to warrant the need for this kind of treatment. Further, the treatment appears to be palliative rather than therapeutic. The submitted chiropractic records do not include any re-evaluations to compare with the initial evaluation which was completed on the said date. Re-evaluations should be performed at least every 60 days. Moreover, the daily office notes lack documentation of listed goals of the treatment plan or comparison to previous treatments. Based on the lack of clinical documentation and the above-cited chiropractic guidelines, the requested therapy is not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for the requested medication Euflexxa for treatment of the enrollees knee pain. Findings:  The physician reviewer found that there is sufficient support for the requested medication in this clinical setting. The evidence-based, peer-reviewed literature supports the use of viscosupplementation injections for the treatment of pain in patients with osteoarthritis of the knee. Viscosupplementation has been found to be safe and effective and allow for delay of total knee replacement. Viscosupplementation has been found to be more effective than corticosteroid injections. In this case, the patient has been diagnosed with bone-on-bone osteoarthritis of the left knee and presents with recurrent left knee pain. Clinical examination findings are consistent with knee osteoarthritis. She has received prior series of Euflexxa injections, with significant pain reduction for six months. She has reportedly failed medications, corticosteroid injections, and physical therapy. The use of Euflexxa is reported to delay total knee replacement due to her young age. 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 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 28-year-old female enrollee requested authorization and coverage of gastric bypass surgery with duodenal switch. The Health Plan denied the request indicating that the requested procedure is considered experimental for treatment of the enrollees medical condition.Three physician reviewers performed an experimental/investigational Independent Medical Review. Two physician reviewers concluded that the requested procedure is not likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy. One physician reviewer concluded that the requested procedure is likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy. Because two of the three  physician reviewers concluded that the requested surgery is not likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy, the Health Plans denial has been upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

A 59-year-old female enrollee has requested for botox injections for treatment of her foot and ankle pain.   Findings:  Two physician reviewers found that Botox is not FDA approved for this patients muscle contractures. This patients muscle contractures are better suited to be resolved by tendon lengthening procedures. The literature in the medical community at this time does not support the use of Botox in this case. Thus, at this time the use of Botox in a case such as this remains investigational and/or experimental and is not likely to be superior to alternative standard therapies.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for DecisionDx-Melanoma testing for evaluation of the enrollees melanoma. Findings:  The physician reviewer found that staging system spelled out by Balch. DecisionDx-Melanoma testing is a study of 31 genes in an individuals melanoma cells. It then classifies that particular melanoma as either class 1 or class 2 based on the risk of metastasis. However, it is not clear how the five-year DecisionDx-Melanoma data compares to the ten-year Balch data. Most importantly, it is not clear whether the DecisionDx-Melanoma can be used to make clinical decisions. Therefore, DecisionDx-Melanoma testing was not likely to have been more efficacious than other methods of evaluating this patient. Final Result: Two of the three reviewers determined that the services at issue were 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: Physician reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in medical oncology 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the Decision DX Melanoma gene assay provided for evaluation of her melanoma.  Findings: Three physician reviewers found that melanoma is a cancer that is curable in its earliest stages. Cutaneous melanoma is initially treated by wide surgical excision and sampling of sentinel lymph nodes for those with high depth of invasion, 0.76-1.0 mm. Metastases to regional lymph nodes may be amenable to excision, but this suggests a high risk for the development of metastatic disease in the future. Such patients may be observed or treated with interferon-alpha.  The data on the Decision DX Melanoma gene assay has not made it part of routine analysis after sentinel lymph node biopsy.  There has also been some lack of consistency between various genes being used as biomarkers. As such, the test is very novel and it is unclear how best to incorporate it into the treatment algorithm beyond standard staging techniques. Thus, Decision DX Melanoma gene assay provided was not likely to have been more beneficial than other available methods of evaluating this patient. Final Result:  Three reviewers determined that the services at issue were 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: Three reviewers are board certified in internal medicine with sub-specialty certification in medical oncology 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: Overturned

The parent of a nine-year-old female enrollee has requested for growth hormone therapy for treatment of the enrollees idiopathic short stature. Findings:  The physician reviewer found that the growth rate increased from 6 cm per year to 9.6 cm per year. the patient has a combination of genetic short stature and constitutional delayed maturation, and she is predicted to achieve an adult stature inside of the FDA guidelines for GH therapy for idiopathic short stature.
Appeal type: Medical Necessity
Decision: Overturned

An enrollee has requested authorization and coverage for Euflexxa injections for the right knee.Current medical literature pertaining to viscosupplementation reveals mixed results. Evidence from eight systematic reviews and six randomized controlled trials indicate that although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known which individuals will benefit. The current evidence is limited, and guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate that the evidence is not conclusive. As such, the Academy does not currently support viscosupplementation as standard treatment for osteoarthritis of the knees. In light of the foregoing, viscosupplementation can only be recommended in individuals with a history of lasting benefit from prior injections and in carefully selected cases when everything else has been tried and the options are limited. In this case, there is documented evidence of good lasting benefit from prior injections. The patient has tried other conservative treatments, but Euflexxa has helped her the most. Under these circumstances, Euflexxa injections for the right knee are medically necessary to treat the patients medical condition.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 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: Overturned

A 24-year-old male has requested approval for residential rehabilitation treatment center services for treatment of his polysubstance dependence.   Findings:  The physician reviewer found that although the patient has a history of anxiety and secondary mood symptoms, the primary issue related to this course of treatment is this patients substance dependence.  For patients with addictive illnesses, the interpretation and application of clinical guidelines and patient placement criteria determines the appropriate level of care.  As noted by the American Psychiatric Association, residential treatment is indicated primarily for patients who do not meet clinical criteria for hospitalization but whose lives and social interactions have come to focus exclusively on substance use.  Per the American Psychiatric Association, residential treatment is indicated for patients who lack sufficient motivation and/or substance-free social supports to remain abstinent in an ambulatory setting. In this patients case, he has multiple psychosocial stressors, including unemployment, strained family relations, and daily drug use.  His social network and daily routine is built around his substance use.  The patient has failed outpatient treatment and questions his ability to stay sober in the community.  He has significant psychiatric comorbidity with increasing affective symptoms, and he has had multiple acute admissions in the past year.  Considering this patients clinical presentation, residential placement is medically indicated.