Persius/imr-appeals huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested a cooling device for approximately 4 weeks for treatment of his medical condition.  Findings:  Two physician reviewers found that the cooling device at issue provides compression and localized cold thermal therapy.  Indications include edema reduction, lymphedema, and chronic venous or arterial insufficiency. Cold compression/continuous-flow cryotherapy is recommended as an option after knee surgery. In the post-operative setting, continuous flow cryotherapy units have been proven to decrease pain, inflammation, swelling, and narcotic usage. However, post-operative use of up to seven days is generally recommended. In this case, the unit was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that a portion of the equipment 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 partially overturned.  Credentials/Qualifications: One reviewer is board certified in physical medicine and rehabilitation with sub-specialty certification in pain management and is actively practicing. Two reviewers are board certified in physical medicine and rehabilitation 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 patient is a 37-year-old male who has a history of hereditary angioedema (HAE), which has been successfully treated with androgens, most recently Oxandrin. The submitted information does not indicate how the diagnosis was confirmed. Additionally, it is not known if C-1-esterase inhibitor function was measured. The patients history suggests that treatment with Oxandrin reduced and/or eliminated episodes of angioedema. Although the patient recently required urgent care for an episode of abdominal angioedema, this was most likely precipitated by his having discontinued use of the drug. At issue is whether Oxandrin is medically necessary for treatment of the patients condition.HAE is effectively treated with attenuated androgens. As one of the submitted articles suggests, Oxandrin is in the class of attenuated androgens along with danazol and stanazol. Though the latter two are more commonly utilized for treatment of HAE, Oxandrin is considered an acceptable alternative to the other attenuated androgens. While Oxandrin has not been approved by the Food and Drug Administration for this indication, the submitted evidence suggests it has been effective for this patient and has not resulted in untoward side effects. Therefore, I have determined that the requested medication is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a six-year-old male enrollee has requested speech therapy for treatment of the enrollee, who has been diagnosed with Down syndrome. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested therapy in this clinical setting.  The current medical evidence supports the requested therapy in this patients case.  Many children with Down syndrome have speech difficulties.  Speech intelligibility is a significant and prominent problem.  It is essential to facilitate development of communication skills in children with global disabilities, particularly when intelligibility is compromised, so that they can express their needs in a functional way.  All told, the requested speech therapy is medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

A 47-year-old female enrollee has requested authorization and coverage for laparoscopy, surgical, with vaginal hysterectomy with removal of tube(s) and/or ovary(s) for treatment of the enrollees pelvic pain and abnormal bleeding. Findings:  The physician reviewer found that based on review of the available records, the patient has a significant history of abnormal bleeding and pelvic pain. In general, the incidence of abnormal uterine bleeding increases as women approach the end of their reproductive years. In this regard, perimenopausal women are not unlike their perimenarchal counterparts. In perimenopausal women, the onset of anovulatory cycles, which are a frequent cause of the abnormal bleeding, represents a continuation of declining ovarian function. Because anovulatory uterine bleeding is by definition an endocrine abnormality, medical management is the preferred method of therapy. The goals of medical treatment for anovulatory bleeding are to alleviate acute bleeding, prevent future episodes of non-cyclic bleeding, decrease the patients risk of long-term complications, and improve the patients overall quality of life. Women who are older than 40 years and who have anovulatory uterine bleeding can be treated with cyclic progestogen, low-dose oral contraceptives, or cyclic hormone replacement therapy. Currently, there are few randomized trials comparing medical therapy versus surgical management for anovulatory uterine bleeding. One randomized trial that compared endometrial resection with medical management for women with menorrhagia found that women who underwent medical therapy were less likely to be satisfied with their therapy. However, because of its reduced risks, medical therapy should be offered before surgical intervention unless it is contraindicated. The American College of Obstetrics and Gynecology (ACOG) Practice Bulletin states that, Surgical therapy is indicated for women with excessive anovulatory bleeding in whom medical management has failed and who have completed their childbearing. Further, the ACOG noted that, Surgical options include hysterectomy and endometrial ablation. Subjective improvement of dysmenorrhea and premenstrual symptoms, as seen in this patient, has been reported following hysterectomy while disadvantages include more frequent and severe intra-operative and post-operative complications when compared with either conservative medical or ablation procedures. This patient does not have evidence of significant pain apart from the dysmenorrhea. As noted above, it can be reasonably expected that the patients dysmenorrhea would improve with resolution of the menorrhagia, and endometrial ablation would therefore be an indicated procedure. There is no evidence in the medical record that the patient has a contraindication to endometrial ablation. Thus, the proposed procedure has not been demonstrated to be medically necessary for management of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for intensive outpatient program (IOP) services at a facility that specializes in dual diagnosis disorders (eating disorder and post-traumatic stress disorder (PTSD)/trauma for treatment of the enrollees bulimia nervosa and PTSD. Findings:  The physician reviewer found that although specialty care services are indicated in this case, the documentation does not support the medical necessity of the requested services. The records do not demonstrate that an eating disordered IOP program in conjunction with outpatient trauma-focused therapy, such as prolonged exposure or cognitive process therapy, would be unsafe or inadequate in this case. Despite twice weekly outpatient visits, that the patients eating disordered behavior worsened after she broke up with her boyfriend. Thus, a higher level of care would be a reasonable course of action, and it appears that the Health Plan offered an appropriate option with IOP level of care. Regarding the trauma-related services, there is no evidence that the patient has failed a course of evidence-based PTSD therapy in the outpatient setting, which is the considered the standard setting for treatment delivery, particularly initial episodes of care, and recovery. As such, a higher level of care is not medically necessary for the diagnosis of PTSD. In sum, the patient should be considered for eating disorder IOP services and a diagnostic evaluation focusing on the appropriateness for a time-limited course of outpatient evidence-based therapy for PTSD. However, the requested IOP services at a facility that specializes in dual diagnosis disorders (eating disorder and post-traumatic stress disorder (PTSD)/trauma) is not supported as medically necessary for treatment of this patients medical condition. 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 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 a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 42-year-old female enrollee has requested for a duodenal switch procedure for treatment of her morbid obesity. Findings:  The physician reviewer found that the duodenal switch procedure is a standard primary treatment for morbid obesity. The peer-reviewed medical literature indicates that this procedure is safe and efficacious in the treatment of morbidly obese patients and has produced durable long-term weight loss outcomes. The American Society for Metabolic and Bariatric Surgery and the American Medical Association based upon numerous published peer-reviewed articles documenting the safety, efficacy and durable long-term outcomes. All told, the requested duodenal switch procedure is medically appropriate and indicated for this patient.
Appeal type: Medical Necessity
Decision: Overturned

The parents of a four-year-old male enrollee have requested authorization and coverage for an ABI Vest for treatment of the enrollees medical condition. The health plan has denied this request indicating that the requested equipment is not medically necessary for treatment of the enrollees cystic fibrosis. One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the health plans denial on the basis that the requested equipment is medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested inpatient hospitalization for eating disorder treatment for the treatment of the enrollees behavioral health conditions.  Findings: The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  The patient was not a danger to herself or others.  She was actively participating in her treatment, attending therapy sessions, and was compliant with her meal plan.  She was medically stable.  She was tolerating her medications.  Although she continued to endorse anxiety and negative associations around mealtime, she had improved and it did not appear that stepping down to a lower level of care would cause her to decompensate.  Per the medical records, she no longer required inpatient level of care.  All told, inpatient hospitalization for eating disorder treatment was not and is not medically necessary for the treatment of this patient.Final Result: The reviewers determined that the services at issue were not and 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 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 a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 64-year-old female enrollee has requested lymphocyte transformation Cyclex Study (86353, 86360, 82397 and 83912) for evaluation of her status post single lung transplant. Findings:  Three physician reviewers found that based upon the peer-reviewed literature, it has not been demonstrated that the requested services would have a beneficial impact on the treatment of the patients immunologic status after her single lung transplant.  The requested assay assesses cell-mediated immunity in immunosuppressed patients. The level of immunity is assessed by ATP levels, and low levels suggest the patient may be prone to infections, while high levels suggest the patient may be prone to rejection.  However, the aggregate of studies has not determined definitive benefit of the assay to evaluate for possible rejection.  The American Society of Transplantation recommendations for the screening and monitoring of infectious complications do not include the immune cell function assay in its recommendations (Humar and colleagues).  Thus, the requested lymphocyte transformation Cyclex Study is not likely to be superior over all other methods of evaluation.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for Nutropin AQ NuSpin 10 mg (J2941). The records provided for review document that this patient has been growing below the third percentile for age and gender for at least two years. The patient was noted to grow 1.75 cm in one year. These factors indicate abnormal growth. In addition, bone age testing was delayed by two years, and the patients testicular size is 3 mL at 12 years of age. Moreover, the patient has a strong family history of constitutional delay of growth in his father and brothers. His current height is significantly below what would be expected from a diagnosis of constitutional delay of growth below -2.25 standard deviations below the mean for age and gender. He passed a growth hormone stimulation test, thus he does not have growth hormone deficiency. The patient was not able to have an MRI of the pituitary. However, it is unlikely a structural lesion would be found, given his growth hormone stimulation test results. His good weight gain excludes poor nutrition as the underlying reason for his poor growth. The patients mother is short for an adult female. She is 4.11, which indicates that she might have an undiagnosed genetic condition that leads to short stature. The possibility of a genetic syndrome in this patient cannot be excluded. This patient had an excellent initial response to growth hormone therapy. Given these findings, the requested Nutropin AQ NuSpin 10 mg (J2941) 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 pediatrics with subspecialty certification in pediatric endocrinology 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 46-year-old male enrollee requested facet injections for medical treatment of his back and shoulder pain.  Findings:  The physician reviewer found that review of the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested services. Based on the documentation submitted for review, there has not been an adequate trial of conservative treatment trialed such as treatment with NSAIDs and physical therapy and there is a lack of specificity in regards to the patients pain generator. In addition, the issue of efficacy of lumbar facet joint injections remains controversial. Therefore, the medical necessity of the requested services has not been established. Based on the medical literature cited above and the records submitted for review, the requested services are not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 61-year-old female with a history of back pain after a work-related injury in 1992. After failing conservative treatment, the patient underwent a multi-level spinal fusion (L2-S1) in February 2001. The patients symptoms improved somewhat for a period of one year after surgery but were then exacerbated by a fall in November 2002. The patient failed to obtain relief from a sacroiliac neurotomy performed in January 2004. The patient has been on methadone, Vicodin, and Neurontin. She has requested authorization for Botox injections. The Health Plan has denied the patients request on the basis that Botox therapy is not medically necessary for treatment of the patients back pain.In the case of this patient with failed back syndrome who is status post multi-level spinal fusion and status post sacroiliac neurotomy, there is no evidence that Botox injections will be effective in providing her with pain relief. Botox therapy has not been shown to be beneficial for patients such as this patient. It is more likely the patient will receive long-term benefit from physical therapy than from Botox injections. Though the patient has been told to avoid heavy lifting, she should be able to participate in physical therapy. Therefore, I have determined that the requested therapy is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a two-year-old female enrollee has requested speech therapy and physical therapy for treatment of the enrollees Down syndrome.  Findings:  The physician reviewer found that the unbalanced Robertsonian translocation involves the presence of extra genetic material to chromosome 21 with a phenotype similar to Down syndrome. This results in hypotonia, motor, cognitive and speech delays.  Low tone slows the acquisition of gross motor skills. Ligamentous laxity with hypotonia complicates the ability to acquire appropriate gross motor skills. Physical therapy with early intervention services in the home 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. Children with Down syndrome have language delays. Expressive language abilities tend to be more delayed than cognitive and receptive language skills. Ongoing speech therapy is necessary to teach sign language as part of a total communication approach to overcome problems in verbal expression and to improve communication. Dysfluency and unintelligible speech are noted in children with Down syndrome and the goal of treatment is to build communication skills while preventing the frustrations and behavioral problems that sometimes result from the protracted period of poor verbal communication. Children with Down syndrome who receive speech-language treatment show better improvement than those who have no treatment.
Appeal type: Medical Necessity
Decision: Overturned

The patients parent has requested authorization and coverage for one-on-one therapy appointments with the same provider twice per week for six months, or in the alternative, one-on-one therapy appointments with the same provider once per week for six months. The American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists Child and Adolescent Level of Care Utilization System (CALOCUS) provides a reliable framework for determining the appropriate level of care for adolescents needing mental health treatment. Using CALOCUS, providers score patients on a scale of 1-5 using a six-pronged Dimensional Rating System. The six dimensions include: (1) risk of harm; (2) functional status; (3) developmental, medical, substance use and psychiatric comorbidity; (4) recovery environment; (5) treatment and recovery history; and (6) engagement. The composite score is then used to determine the level of care needed. This gives the patient a composite score which is consistent with high intensity community-based services. The chart documents that the patient has already participated in traditional IOP and PHP, yet she continues to have significant symptoms. Given the patients nonverbal learning disorder and her history of trauma, consistency in her treatment plan will be important for her recovery. Her care needs to be trauma-informed and sensitive to the ways in which her nonverbal learning disability may affect comprehension and communication. Given these findings, the requested individual therapy twice per week with the same provider is medically necessary for this patient. After her symptoms improve, the frequency could be reduced to one time per week. Although it is difficult to predict the required length of care, given the patients combination of trauma, mood symptoms, as well as academic difficulties, it is reasonable to expect that patient will require ongoing weekly therapy for at least six months at a frequency of twice per week. Therefore, the requested one-on-one therapy appointments with the same provider twice per week for six months 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 psychiatry with subspecialty certification in child and adolescent 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 a similar medical condition.