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

The parent of a six-year-old male enrollee has requested speech therapy for the treatment of the enrollees apraxia. Findings:  The physician reviewer found that the patient has been diagnosed with childhood apraxia of speech, with delays in expressive and receptive language as well as phonologic delays. The submitted documentation demonstrates through objective testing that this patient has made gains with speech therapy beyond what would be expected in a standard time frame. He continues to have language skills below age level, but did demonstrate progress with the disputed therapy. This patients deficits can be consistent with intermittent hearing loss. All told, speech therapy was necessary and appropriate from a medical standpoint.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a thirteen-year-old male enrollee has requested for occupational therapy for treatment of the enrollees autism. Findings:  The physician reviewer found that occupational therapy has improved this patients fine motor skills to the point of being able to tie his shoes, utilize buttons and overall improve his fine and gross motor skills. Occupational therapy has been utilized for many years to improve motor skills in autistic children. The peer-reviewed papers referenced discuss occupational therapy in autistic and developmentally disabled children. Occupational therapy is well established as beneficial for this disabled pediatric population, and it is medically indicated for treatment of the motor deficiencies in patients such as this patient.
Appeal type: Medical Necessity
Decision: Overturned

A 60-year-old female enrollee has requested skilled nursing facility treatment for evaluation of her post left total hip replacement. Findings:  The physician reviewer found the submitted documentation establishes the medical necessity of skilled nursing facility treatment. In this case, skilled nursing personnel is medically necessary to maintain the patients safety to prevent falls and prevent non-compliance with hip precautions. Thus, the patient required supervision for maximum cueing for maintaining her range of motion precautions while doing her functional tasks. The evidence-based literature cited above shows that the risk of hip dislocation increases with female gender and with non-compliance with standard hip precautions. Thus, the patient was not appropriate for transition to custodial care as she was still making gains in therapies and had reasonable goals and plans to achieve an independent level of function with adaptive equipment to get home safely. Had the patient been discharged home at this time she would have been at a high risk for hip dislocation and for falls. Accordingly, the skilled nursing facility treatment is medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary:    An enrollee has requested water circulating cold pad with pump (CPT E0218) for treatment of his medical condition.  The physician reviewer found that the patient underwent left knee arthroscopy with extensive tricompartmental debridement, partial medial and lateral meniscectomies, and patellofemoral chondroplasty.  Evidence-based medical guidelines and peer-reviewed literature generally support the use of cryotherapy in the postoperative period following knee arthroscopic surgery.  However, there is a lack of large volume, long-term studies evidencing significant overall outcome differences with regards to continuous flow cryotherapy versus standard cold packs, in surgeries of this type. Therefore, the water circulating cold pad and pump was not likely to have been more beneficial for the treatment of the patients medical condition than standard cold packs. Final Result: Three reviewers determined that the device at issue was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.  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 42-year-old female enrollee has requested reimbursement for transcranial magnetic stimulation therapy provided from over an approximate 5-week timeframe for treatment of the enrollees major depressive disorder. Findings:  Two physician reviewers found that the patient has major depressive disorder.  In a letter, the provider noted that the patient had only a partial response to a prior course of electroconvulsive therapy nine years prior.  Per the provider, the patient failed treatment with multiple medications, including Wellbutrin, Lexapro, Zoloft, Abilify, Lamictal, Geodon, Seroquel, Ativan, Ambien, and Pristiq.  Her symptoms include anxiety, poor sleep, poor concentration, low energy, fatigue, anhedonia, interpersonal withdrawal, and suicidal ideation.  The patient has requested reimbursement for transcranial magnetic stimulation provided during the dates in question.  In this patients case, the services at issue were not likely to have been more efficacious than other treatment options.  Per the submitted documentation, the patient experienced minimal benefit from transcranial magnetic stimulation.  The patients Zung score changed very little throughout the sessions that she received.  Although the patient experienced some improvement, this was not lasting.  Additionally, the improvement was accompanied by reinstituting weekly psychotherapy and adding Lamictal to her regimen.  Thus, it is not clear that this improvement was a result of the transcranial magnetic stimulation.   The submitted medical records do not demonstrate that the patient had exhausted available standard therapies prior to undergoing transcranial magnetic stimulation.  All told, transcranial magnetic stimulation provided during the timeframe in question was not likely to have been of greater benefit than other treatment modalities.
Appeal type: Medical Necessity
Decision: Upheld

A female enrollee requested authorization and coverage of Botox injections. The Health Plan denied the request indicating that the requested therapy is not medically necessary for treatment of the enrollees headaches.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested therapy is not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

A 53-year-old female enrollee has requested a power scooter for treatment her back and left leg pain. Findings:  The physician reviewer found that the requested equipment is medically necessary for treatment of the patients medical condition. The medical literature supports the requested equipment in this clinical setting. According to Edwards and colleagues, Power wheelchairs and scooters have the potential to increase community participation for people with mobility limitations. The authors investigated the characteristics of adults who use power wheelchairs and scooters, the process of power-mobility provision and the benefits and challenges of use. The authors note, The benefits of power-mobility devices are reported to include improved quality of life, an increased sense of freedom and improved self-esteem.  In this case, the patient has impaired functional mobility due to permanent neurologic deficits and is not able to use lesser devices than a power scooter to safely traverse her environment. She has had accidents using a bicycle for transport and is unable to propel a manual wheelchair. She is having adverse psychological effects from being confined to her home due to limited functional mobility. In sum, a power scooter is medically necessary to maximize her independence, physical health, and mental health. Based on the medical literature and documentation submitted for review, requested equipment is medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 57-year-old male enrollee has requested medical therapy with Pegasys or Peginterferon alpha-2a and Ribavirin for treatment of his hepatitis C.  Findings:  The physician reviewer found that Hepatitis C virus (HCV)-related end-stage liver disease is the leading clinical indication of liver transplantation (LT) in the United States as reported by the Bureau of Health Resources Development. HCV recurrence after LT is almost universal and occurs early, with histological recurrence observed in up to 70% of patients during the first year after LT (Gane, 2003). Cirrhosis develops in up to 30% of transplant recipients after 5 years with persistent HCV viremia, and may be associated with graft failure and the need for re-transplantation (Gane, 1996). This leads to lower patient survival rates compared to non-HCV transplant recipients (Forman, et al). Eradicating HCV using antiviral therapy improves patient and graft survival (Veldt, et al). Regimens combining Ribavirin (RBV) with pegylated interferon (PEG) report rates of sustained virological response (SVR), ranging from 28% to 45% with up to 48 weeks of treatment (Bizollon, et al). Currently, there are no established guidelines to determine the timing and type of HCV treatment after LT. In general, the approach to the treatment of HCV after liver transplantation is similar to the pre-transplant protocol of 48 weeks of treatment with viral kinetic evaluation at 12 and 24 weeks. One study reported that patients with recurrent HCV after LT are likely to be slow virological responders due to immunosuppression (Hashemi, et al). Therefore, SVR after 48 weeks of antiviral therapy is expected to be lower than in immune-competent HCV patients. Overall, 73% experienced end of treatment of response and 60% had SVR. The conclusion of the study was that recurrent HCV after LT can be safely treated with extended virological response-guided therapy using PEG/RBV, but requires close monitoring for treatment-related adverse effects, particularly cytopenias (Schmidt, et al). Therefore, based upon the data from various studies using extended therapy in post-transplant HCV, it is appropriate and medically necessary to use extended therapy with pegylated interferon and Ribavirin to have a better chance of achieving SVR in these patients and thereby improve graft and patients survival, and prevents the patients from undergoing re-transplantation.
Appeal type: Medical Necessity
Decision: Upheld

A 41-year-old female enrollee has requested for pudendal nerve injections and pelvic physical therapy (PT)  for treatment of her pelvic pain.    Findings:  The physician reviewer found that this patient has completed an extensive pelvic floor PT program and should be independent with her home exercise program (HEP) at this point.  On-going skilled pelvic PT has limited additional value beyond compliance with the HEP.  Occasional pudendal nerve injections for intermittent severe, sharp neuropathic symptoms may be medically justified, but not until chronic medication management has been optimized with use of pain medications for breakthrough pain.
Appeal type: Medical Necessity
Decision: Overturned

A 54-year-old female enrollee has requested for Xenicalfor treatment of her obesity. Findings:  The physician reviewer found that Xenical is approved by the FDA at the prescribed dosage for obese patients with a BMI greater than 30. Xenical has been found to contribute significantly to successful weight loss when compared to the results achieved with diet and exercise alone. The Xenical studies did not include a weight loss of 10% as a pre-condition for enrollment and there is no clear medical indication for such a requirement. The patient has a BMI greater than 30 with significant co-morbidities and treatment with Xenical is consistent with the FDA guidelines. Although the benefits of Xenical for a patient such as this one are clear, there are a number of precautions related to its use and reports on the benefits do not extend beyond two years of therapy.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for brand Xopenex inhaler and brand Xopenex nebulized solution.Short-acting beta agonists (SABA), including brand-name Xopenex inhaler and brand-name Xopenex nebulized solution, are approved by the U.S. Food and Drug Administration, supported by the medical literature, and included in professional treatment guidelines for the management of asthma. In this case, the patient has tried and failed other SABA alternatives due to severe agitation/anxiety. Given concurrent anxiety and attention deficit hyperactivity disorder, the patient has benefited from the lung-specific stereospecificity of levalbuterol (Xopenex), which has minimized off-target, systemic adrenergic effects. Thus, brand Xopenex inhaler and brand Xopenex nebulized solution are medically necessary for the treatment of the 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 internal medicine with sub-specialty certification in pulmonary 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for the DecisionDx-Melanoma Gene Assay testing. Findings:  Three physician reviewers found that the DecisionDx-Melanoma Assay tests the tissue genetics of the melanoma to help stratify whether a melanoma is high risk for metastasis. The DecisionDx-Melanoma Gene Assay has shown some accuracy in thin melanomas. However, there is a lack of scientific evidence permitting conclusions concerning the effect of this test on health outcomes. The test is not considered routine standard of care and is not recommended by the National Comprehensive Cancer Network (NCCN) guidelines. Since this test has not been demonstrated to provide superior benefit compared to established tests, the DecisionDx-Melanoma Gene Assay provided was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: 3 of 3 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: All three Physician reviewers are board certified in dermatology 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 14-year-old male enrollee requested coverage for 4 hours per week of direct applied behavioral analysis (ABA); 4 hours per week of ABA parent training and 2 hours per week of ABA supervision for medical treatment of the enrollees autism spectrum disorder (ASD).  Findings:  Three physician reviewers found that based on the documentation submitted for review, the request for 4 hours per week of direct ABA; 4 hours per week of ABA parent training and 2 hours per week of ABA supervision is medically necessary for treatment of the patients ASD. Applied behavioral analysis is an effective modality for many patients with autism.  In addition, there is evidence that supports the efficacy of ABA parent training.  Parental participation in therapy is associated with better outcomes.  As such, parent training at the frequency of 4 hours per week is clinically indicated and medically necessary for treatment of the patients medical condition.
Appeal type: Urgent Care
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for emergency medical services. Findings:  The physician reviewer found that the medical services provided were not necessary for treatment of an emergency medical condition. The documentation submitted for review does not demonstrate evidence of an emergency medical condition. The medical records provided for review, fail to show past medical history addressing a mechanism of injury leading to the reported acute presentation or evidence of chronicity. In addition, there is no documentation of imaging to rule out underlying injury/pathology that would lead to the reported emergency presentation. Therefore, the services provided are not considered emergency medical services. Thus, the patient did not receive emergency medical services on the date of service at issue. Final Result: The reviewer determined that the patient did not receive emergency medical services on the date of service at issue. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in oriental medicine and 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: Upheld

A 52-year-old female enrollee requested monitored anesthesia care during a colonoscopy for treatment of her medical condition.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services.  The standard of care for monitored anesthesia care for a minimally invasive procedure is airway difficulty, large fluid shifts and comorbid conditions that would put the patient at risk during the procedure.  In this patients case, the criteria for monitored anesthesia care have not been met.  This patient did not present with a significant history that would require monitored anesthesia care.  Colonoscopy may be safely and effectively performed with conscious sedation of a benzodiazepine alone or with a narcotic in an office-based setting and without the need of monitored anesthesia care.  All told, monitored anesthesia care was not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for the medication Premarin (hormone replacement therapy). The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees post-menopausal symptoms. At issue in this case is whether the requested medication Premarin (hormone replacement therapy) is medically necessary for treatment of the enrollees medical condition.Post-menopausal vasomotor symptoms (hot flashes) result in significant impairment of activities of daily living when they are severe. According to various medical societies including the North American Menopause Society, the recognized, preferred and effective therapy is estrogen replacement. This may be in oral or transdermal form. The medication Premarin (hormone replacement therapy) is an oral form of estrogen used for hormone replacement therapy. For a woman with a uterus, the estrogen must be balanced with progesterone to protect against endometrial cancer. In this case, in order to improve this woman's quality of life by reducing significant hot flashes, estrogen therapy is medically necessary. It is advised that this therapy be discontinued by age 60. Therefore, the requested medication Premarin is medically necessary.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 obstetrics and gynecology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for the Orthovisc injections. Hyaluronic acid injection for osteoarthritic knee pain is an established part of osteoarthritic knee pain treatment algorithms and generally considered a second-line treatment after independent exercise, weight loss and simple medications such as nonsteroidal anti-inflammatory medications or acetaminophen. With long-term data supporting widespread use, the injections have been confirmed to be safe with no severe or systemic side effects. In contrast, nonsteroidal anti-inflammatory pain medications, acetaminophen, opioids and oral or intra-articular corticosteroids can have serious systemic side effects and are not reasonable treatment options for some patients. This patient had adequate relief of severe osteoarthritic symptoms with prior hyaluronic acid injection. For these reasons, the requested Orthovisc injections are supported as medically necessary for treatment of this patients bilateral knee osteoarthritis.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: Medical Necessity
Decision: Overturned

A 21-year-old female enrollee has requested a reduction mammoplasty for treatment of her macromastia. Findings:  The physician reviewer found that the American Society of Plastic Surgeons (ASPS) guidelines argues that a minimal weight should not be required and that reduction mammoplasty is considered reconstructive surgery and medically necessary for symptomatic macromastia patients when two of the following criteria are met: chronic breast pain caused by weight of the breasts, intertrigo unresponsive to medical management, upper back, neck and shoulder pain, unspecified backache, acquired thoracic kyphosis, shoulder grooving from bra straps, headache, congenital breast deformity and upper extremity paresthesia caused by brachial plexus compression syndrome secondary to the weight of the breasts being transferred to the shoulder strap area. This patient is documented by the plastic surgeon to have macromastia with significant breast pain, back pain, neck pain and shoulder pain.  The patient has attempted treatment with non-operative measures without success. As documented by Freire, et al., neck, shoulder, and lower back pain and reduction of functional capacity can be caused by breast hypertrophy and successfully treated with breast reduction. Thus, based on the recommendations of the ASPS, this patient would satisfy medically necessary criteria. With respect to the amount of tissue resected, the ASPS has stated that there is Level II evidence that indicates that resection volume is not correlated to the degree of postoperative symptom relief and thus a minimum amount is not required.