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

Nature of Statutory Criteria/Case Summary: A enrollee has requested authorization and coverage for enoxaparin sodium (Lovenox) twice daily. Findings:  The physician reviewer found that this patients records support the medical necessity of the requested Lovenox twice daily. The magnetic resonance imaging (MRI) findings, positive serology, and presence of cutaneous vasculitis demonstrate an indication for this medication. Moreover, Lovenox is considered the standard of care in this clinical setting. All told, the requested Lovenox twice daily is medically necessary for treatment of this patients medical condition. 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 nephrology 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 62-year-old female enrollee has requested for MRI guided steroid injections for treatment of her pudendal neuralgia.   Findings:  Three physician reviewers found that there is a lack of scientific literature supporting this approach. These services were of unproven efficacy and not medically indicated in this setting.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Synvisc One injections for the treatment of his medical condition. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  Based upon a review of the recent literature, evidence-based guidelines no longer support viscosupplementation for osteoarthritis of the knees.  Jevsevar and colleagues performed a study of viscosupplementation for osteoarthritis of the knee.  The meta-analysis of the double blinded, sham-controlled trials with at least 60 patients did not show clinically important differences of hyaluronic acid treatment over placebo.  When all literature was added to the analysis, the overall effect was greater but was biased towards stronger treatment effects because of the influence of non-blinded or improperly blinded trials.  There is a lack of support for the requested services in this clinical setting.  All told, the requested Synvisc One injections are not medically indicated for the treatment of this patient.   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 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

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement for the gene panel testing. Findings:  The physician reviewer found that the gene panel testing performed was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Genotype testing for genetic polymorphisms to determine psychotropic drug metabolizer status holds promise for improving the treatment of individuals with autism spectrum disorder who could benefit from pharmacotherapy. However, at present time there are insufficient controlled, adequately powered published studies to support its general adaptation . Variables such as age, sex, precision of diagnosis and environmental influences have not been addressed in currently available published studies. For the reasons provided, the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: All three of the reviewers determined that the testing at issue was 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 & 3 are board certified in pediatrics and neurology with special qualification in child neurology 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

A 49-year-old male enrollee has requested an electric microprocessor knee-shin swing/stand prosthetic (Otto Bock C-Leg system) and related accessories for treatment of his left above knee amputation.  Findings:  The physician reviewer found that the literature supports the functional benefits of microprocessor-controlled prosthetic knees for active community ambulators with transfemoral amputations. Given the findings by Hadley and colleagues, this patient is an appropriate candidate for this type of prosthesis, given his age, functional status, and active lifestyle. His current prosthesis is in marked disrepair and requires replacement. Applying the conclusion published by Seymour and colleagues, replacement with a new prosthesis with a microprocessor-controlled prosthetic knee is consistent with current clinical standards of practice. Moreover, provision of the requested equipment should further enhance the patients gait, reduce his risk for falls, and decrease barriers to a more active overall lifestyle. Therefore, the requested equipment has been demonstrated to be medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

A 46-year-old female enrollee has requested an abdominoplasty for treatment of her medical condition. Findings:  The physician reviewer found that the patient does have a pannus (grade I to II), as the submitted photographs confirm. However, as per the recommendations of the American Board of Plastic Surgery, this patient does not meet criteria for abdominoplasty as her weight has not been stable for six months. In addition, the patient reported experiencing medication-based weight gain, and the records do not indicate that these medications have been or will be discontinued. Thus, the patient will likely continue to gain weight after the proposed abdominoplasty. Furthermore, the records do not document chronic and persistent panniculitis, cellulitis, non-healing skin ulceration, which is refractory to at least three months of treatment. All told, the patient does not meet medical necessity indications for the proposed procedure.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a four-year-old female with a proximal femoral focal deficiency (PFFD), Type D. Her right leg is approximately 16 cm shorter than the left, externally rotated, and the enrollee has a very short thigh. The patients mother is seeking authorization for a Super Hip procedure. The Health Plan has denied this request.The patient requires treatment. There are a number of procedures and therapies available for the patient. The procedure requested by the patients parent is reasonable and indicated for the patient. There is sufficient evidence that the requested procedure will benefit the patient and that it is the treatment of choice for this patient. Therefore, I have determined that the requested procedure is medically necessary for treatment of the enrollees medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for lactic acid dehydrogenase (LDH) isoenzyme blood test for evaluation of the enrollees stiffness and joint pain. Findings:  The physician reviewer found the request for LDH isoenzyme blood testing is not medically necessary for evaluation of the patients medical condition. According to the peer-reviewed evidenced based guidelines, LDH isoenzyme test is not a recommended serology in the evaluation and treatment of arthralgia and myalgia. Given the lack of support in the peer-reviewed literature, LDH isoenzyme testing is not supported as medically necessary for evaluation of the patients medical condition. Final Result: The reviewer determined that the requested testing is not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in rheumatology 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 or cervical facet joint injections for treatment of his neck pain with right upper extremity radiculopathy.   Findings:  The physician reviewer found that the patients complaints and imaging findings are not amenable to treatment via cervical facet injections. The patient has a disc complex with cord compression. A facet injection would not provide any benefit in this clinical setting. Facet injections are useful for treating facet joint disease of the spine and can be helpful in alleviated axial neck pain without radiculopathy. The standard of care in this patients circumstance includes cervical epidural steroid injections and not cervical facet injections. Thus, the requested cervical facet joint injections are not 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 anesthesiology with sub-specialty certification in pain 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: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested residential treatment center (RTC) services for treatment of her behavioral health conditions.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  Modern psychiatric practice aims to place patients in the least restrictive treatment setting to optimize treatment gains and foster autonomous resilience.  In this patients case, she did not have a psychiatric condition that necessitated a 24-hour supervised setting.  She was neither psychotic nor suicidal.  She was adherent with her medications and had just started an anti-craving agent.  Upon presentation, the patients body mass index (BMI) was well within normal limits.  She had no significant medical issues.  The patient struggled with food rituals and adherence to the meal plan, but she was active in treatment and motivated for recovery.  Further, she had a supportive spouse and safe residence while the extent and outcome of less restrictive interventions during the episode of illness were unclear.  This patient required comprehensive treatment to address her eating disordered schemas, anxiety, addiction, and mood.  However, treatment in a 24-hour supervised setting was not for the treatment of this patient.  Final Result: The reviewer determined that the services at issue were 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: Upheld

A 50-year-old female enrollee requested Zofran 4 mg tablets, #90 (three times per day for medical treatment of the enrollees nausea and vomiting.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication quantity.  The patient has recurrent nausea and vomiting, and the etiology has not been identified.  This patient is not postoperative or receiving an emetogenic chemotherapy agent.  The medical records do not establish the need for Zofran 4 mg tablets, #90 (three times per day).  Other agents can be tried prior to use of Zofran, including Reglan, Tigan and prochlorperazine.  All told, Zofran 4 mg tablets, #90 (three times per day) is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

A 36-year-old male enrollee has requested a gastric bypass procedure for the treatment of his medical condition. Findings:  The physician reviewer found that before weight loss surgery, it is necessary to ensure that there are no behavioral, dietary, or metabolic barriers to the success of the surgery.  In this case, there is no evidence to remove these barriers. There is no evidence of reasonable dietary attempts, multidisciplinary evaluation or normal TSH level.  Although this patient is morbidly obese and may benefit from weight loss surgery, at this time the medical necessity of this procedure is not substantiated by the record.
Appeal type: Medical Necessity
Decision: Overturned

A 46-year-old male has requested a duodenal switch procedure for treatment of his obesity.  Findings:  The physician reviewer found that the current medical evidence supports the requested procedure in this clinical setting.  This patient meets all standard nationally accepted criteria for bariatric surgery.  The requested procedure is a standard primary treatment for morbid obesity and is approved by the American Society for Metabolic and Bariatric Surgery.  He has failed dietary efforts in the past, and he has completed a thorough multidisciplinary evaluation that did not reveal any obvious dietary, behavioral, or medical barriers to surgery. The patient has serious weight-related comorbid conditions including long standing diabetes mellitus, hypertension, and sleep apnea.
Appeal type: Medical Necessity
Decision: Upheld

This patient is a 32-year-old female who is currently pregnant and has not been diagnosed with cancer. However, the patients mother was recently diagnosed with ovarian cancer and the mothers sister died of breast cancer and her age at diagnosis is unknown. The patients mothers mother died of cervical/uterine cancer and her mothers brother may have colon cancer, but this has not been confirmed.  Due to her family history, the patient is requesting authorization for BRCA testing to detect a genetic susceptibility to cancer. The Health Plan denied her request for authorization citing a lack of medical necessity.BRCA testing detects certain gene mutations that significantly increase the risk of ovarian and/or breast cancer. These mutations are usually detected in families wherein there are a number of young women with breast cancer and/or ovarian cancer; overall these are rare findings. Criteria have been established so that the testing is only done in women who might reasonably test positive. In women who have not had cancer, the Health Plans authorization criteria require a family history of three or more relatives with breast or ovarian cancer, at least one of which is a first degree relative (e.g. mother or sister). These criteria provide a reasonable method for determining if BRCA testing is medically indicated, and the patient clearly does not meet the criteria. Therefore, I have determined the requested services are not medically necessary for evaluation of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for the medication Epidiolex.The medical literature supports that the requested medication is medically necessary. Epidiolex is a pharmaceutical formulation of highly purified cannabidiol (CBD) in oral solution, 100 mg/ml, usually administered at 2-10 mg/kg/day. Silvestro and colleagues have explained that CBD is one of the cannabinoids with non-psychotropic action, extracted from Cannabis sativa. They have stated that this compound has shown efficacy as an anti-seizure, antipsychotic, neuroprotective, antidepressant and anxiolytic medication. The compounds neuroprotective activity appears linked to its excellent anti-inflammatory and antioxidant properties. A study has found that the results of scientific studies obtained so far for the use of CBD in clinical applications could represent hope for patients who are resistant to all conventional anti-epileptic drugs. Epidiolex has been demonstrated to be an effective long-term treatment option in Lennox Gastaut syndrome and Dravet syndrome, two forms of intractable generalized epilepsy syndromes in children, and it is approved by the U.S. Food and Drug Administration (FDA) for those conditions. The pharmaceutical company which manufactures Epidiolex obtained FDA approval for the drug's use in Lennox Gastaut syndrome and Dravet syndrome, both of which are conditions eligible for the orphan drug pathway because this enabled them to bring the medication to market with fewer phase 3 pivotal efficacy randomized controlled clinical trials. Epidiolex does not have biological specificity for these two conditions, however, and medical literature has noted that open-label studies with 100 mg/ml CBD (Epidiolex) have provided additional evidence of its efficacy along with an adequate safety profile (including certain drug interactions) in children and young adults with a spectrum of treatment resistant epilepsies.In this case, the patient has medically refractory epilepsy. She has been evaluated with video EEG telemetry at a major tertiary epilepsy center, and no surgically treatable lesion was found. She continues to have 1-2 prolonged generalized tonic seizures per week during sleep. This puts her at high risk for sudden unexpected death in epilepsy (SUDEP). As noted above, the medical literature supports the use of Epidiolex in patients with a spectrum of treatment resistant epilepsies. Accordingly, the medication Epidiolex is medically necessary for the patients condition.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, neurology, and neurology with special qualification in child neurology, and is actively practicing. The reviewer is an expert.
Appeal type: Medical Necessity
Decision: Upheld

A 64-year-old female enrollee requested authorization and coverage of an orthopedic referral for the treatment of spinal pain.  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 referral is not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 51-year-old female enrollee has requested Nexium for the treatment of her gastrointestinal condition. Findings:  The physician reviewer found that a number of studies demonstrate the efficacy of each of the PPIs for the treatment of both peptic ulcer disease and GERD. However, there is no data that demonstrates superior efficacy of one PPI above another. Given this, choice of PPI becomes a matter of individual tolerability and efficacy. The fact that a patient has been on a specific PPI for years does not mean that an alternate PPI will not be effective. The Health Plans requirement that the patient try 4 other PPIs prior to Nexium is medically reasonable given the fact that all PPIs have equivalent efficacy. In this case, the patient has tried 3 of the required PPIs in the past, although the dose and duration were not specified and therefore it is impossible to determine if these were given an adequate trial. In addition, the patient has no documentation of a trial of Prevacid.
Appeal type: Medical Necessity
Decision: Upheld

This patient is a 13-year-old female with a history of ataxic cerebral palsy with cognitive delays, expressive and receptive language delays and dysarthria. She has been receiving speech therapy through the school system and privately from 9/01 through 12/05, based on the records provided. The Health Plan denied the parents request for reimbursement and continued authorization of speech therapy based upon a determination that the therapy was/is not medically necessary.I evaluated all of the private speech therapy progress notes from 9/01 through 12/05 in the course of my review. The evaluations use primarily a narrative format for assessment, with no real quantification of the patients progress.  The two most recent reports of 7/05 and 12/05 fail to outline goals and objectives for the patient and there is no documentation of improvement between the 7/05 evaluation and the 12/05 evaluation.  Instead, the comments in the 12/05 report refer back to the initial evaluation in 2001 for comparison and measurement of progress. This documentation does not support a conclusion that the patient is making functional progress. Therefore, I have determined the therapy at issue was/is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 29-year-old female who has requested authorization for a hysterectomy because of pelvic pain. She has undergone extensive workup without any evidence of a gynecological etiology for her complaints.  The Health Plan has denied authorization for the requested hysterectomy on the basis that the procedure is not medically necessary.The patient has seen numerous gynecologists and the general consensus has been that she has no indication for a hysterectomy. The submitted medical records including physical exams, laparoscopy and sonograms do not indicate any pathology that would substantiate a need for surgery. As such, it is not likely a hysterectomy will be beneficial for the patient and therefore, it is not medically warranted. Accordingly, I have determined the requested procedure is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.