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

The patient is a 53-year-old male who has lymphedema and a history of renal cancer, testicular cancer, and prostate cancer. He is post nephrectomy, prostatectomy and node dissection, and cervical lymph node excision. In July 2004, the patient experienced swelling over most of his body. He has undergone a trial of compression stockings and Lasix treatment for his condition without success. He has requested a referral for a consultation and follow-up care with an out-of-network lymphedema specialist. The Health Plans denial should be upheld. Based upon the information provided, it does not appear the patient is receiving ongoing care from the out-of-network specialist. The patient has not yet consulted an in-network vascular surgeon. A consultation with an in-plan vascular surgeon should take place as soon as possible. If the in-network vascular surgeon recommends a referral to the out-of-network lymphedema specialist, the patients request should be reconsidered. As such, I have determined that the requested referral is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

A 69-year-old female enrollee has requested physical therapy services for treatment of her knee pain. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue. Per the medical records, this patient should have been independent with a self-directed exercise and modality program after an initial exercise instruction session.  There were no significant impairments that would have precluded an independent program, and there were no documented exercises that she was performing in physical therapy that she could not have performed on her own or substituted with independent exercise.  There is no proven benefit of long-term passive modalities such as manual therapy for this condition.  All told, physical therapy services were 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 Euflexxa viscosupplement injections. The current literature continues to support the use of viscosupplementation for osteoarthritis of the knees. There is good evidence that intraarticular hyaluronic acid injections reduce pain and increase function in knee osteoarthritis, and the benefits are long-lasting as compared with intraarticular corticosteroids. Evidence from studies of repeat courses of intraarticular hyaluronic acid demonstrates an improvement in pain or function lasting up to 40 months, a reduction in use of concomitant analgesia by up to 50%, and suggests that there may be a delay in the need for total knee replacement of around 2 years. The reviewer found that the current highest level of evidence suggests that intraarticular hyaluronic acid is a viable option for knee osteoarthritis and that its use results in improvements in knee pain and function that can persist for up to 26 weeks. Intra-articular hyaluronic acid has a good safety profile, and its use should be considered in patients with knee osteoarthritis. There is sufficient support for the requested services in this clinical setting. Therefore, Euflexxa viscosupplement injections 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.Findings:  The physician reviewer found that
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 15-year-old male with a diagnosis of idiopathic short stature. He is being followed by pediatric endocrinologists. He had a low IGF-1 level of 192, but normal IGFBP-3 level. His bone age at 14 years 1 month was 13 years 6 months, which showed no significant delay, giving him a predicted adult height of 53 based upon his height at that time. The mid-parental height was listed as 67 inches. It is presumed thyroid tests were normal. There is no evidence GH stimulation tests were performed. The patients puberty was advancing and he was at Tanner stage 3 more than 1 year ago. He began growth hormone therapy in October 2004. Prior to starting growth hormone therapy, the patient had grown 10.2 cm in 22 months. After beginning growth hormone therapy, the patient grew 6.9 cm in 7-8 months (as of March 2005).  The patients provider has recommended the patient continue to receive growth hormone therapy. The Health Plan has determined growth hormone therapy is not medically necessary for treatment of the patients condition.As documented in the records provided, the patient does fulfill the FDA approved criteria for growth hormone therapy for idiopathic short stature as well as the American Association of Clinical Endocrinologists Medical Guidelines for Clinical Practice for Growth Hormone. The patient has had a doubling of his growth rate in height since beginning growth hormone therapy. This therapy should therefore continue until growth has ceased. Therapeutic consideration of the means to extend his growth period with advancing puberty is being appropriately considered. Accordingly, I have determined the requested therapy is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Upheld

A 58-year-old male enrollee has requested chemosensitivity laboratory testing (ChemoFx assay) for evaluation of his lung cancer. Findings:  Three physician reviewers found that there have been many attempts to study chemosensitivity assays as to their capability to aid the oncologist in selecting specific chemotherapeutic agents for an individual patient.  These assays grow cancer cells in vitro and test their resistance to various drugs. At this time, there is a lack of convincing clinical data demonstrating that one can improve the survival of patients with non-small cell lung cancer by selecting a drug based upon an assay. There is a small study suggesting the clinical benefit of the selection of drugs by the assay for patients with ovarian cancer.  However, at this time, the superior efficacy of the testing at issue has not been established for evaluation of individuals with this patients diagnosis.
Appeal type: Experimental/Investigational
Decision: Upheld

A 57-year-old male enrollee requested the UroLift procedure for medical treatment of his benign prostatic hyperplasia.  Findings:  Three physician reviewers found that in this patients case, the requested services are not likely to be superior over other treatment options.  This patient has been diagnosed with prostate cancer.  However, the records do not document a repeat biopsy to determine if there has been any progression of disease.  Per the medical evidence, there is a lack of support for the UroLift procedure for patients with known prostate cancer.  At this time, long-term studies are needed to support the safety and efficacy of this procedure.  Thus, the requested UroLift procedure is not likely to be more effective than other available modalities.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a 10-year-old male enrollee has requested  for speech therapy for treatment of the enrollees articulation disorder and word-finding deficits.  Findings:  The physician reviewer found that there is no evidence presented in the documentation supporting a medical need for speech therapy. No aspects of the perinatal history or the achievement of early developmental milestones, speech or otherwise, were noted as contributing to the patients speech pathology. There is no supportive documentation from the pediatrician indicating an assessment of medical conditions related to speech deficits nor is there a neurological or developmental assessment. There is no clinical evidence of swallowing or oral/motor dysfunction. The etiology of the patients speech disorder is not clear nor is it apparent whether or not it is related to a more global developmental issue.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 10-year-old male with autism who has been receiving occupational therapy and individual speech therapy for many years. He also has a history of seizure disorder, sensory integrative dysfunction symptoms and dyspraxia. The patients therapist notes that progress has been difficult secondary to the patients behavioral and mood issues. The therapist has documented some gains in speech specifically with sight words, and the use of two to four word phrases. The patients therapist has recommended a decreased frequency of two therapy sessions per week. At issue is whether continued speech and occupational therapy is medically necessary for treatment of the patients autism.Upon review of the submitted records, there appears to be an inconsistency between the therapy goals listed in the July 2004 evaluation and those in the progress report dated 1/25/05. There is no evidence in the submitted materials that the patient achieved the goals established in July 2004. Furthermore, several goals in the January 2005 report are related as much to the home program as to the actual therapy. Based upon the documentation provided, there is insufficient evidence the patient has made significant progress with therapy. As such, it is unlikely the patient will experience clinical benefit from continued 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested acute inpatient psychiatric services provided for treatment of his behavioral health condition.   Findings:  The physician reviewer found that according to the documentation submitted for review, the patient appears to have a medical disorder in context of a serious formal thought disorder, which as a class represents the most severe of psychiatric illnesses. He has multiple risk factors, and his particular condition is consistent with the conceptualization of grave disability. Prematurely discharging a patient under such circumstance would be inconsistent with contemporary practice standards, thus a conservative hospitalization was to be expected. Although formidable chronicity had declared itself, the patient was still gravely disabled. He remained engaged in active treatment services that were reasonably expected to prevent a worsening of his condition.  The inpatient team was adjusting a complex balance of multiple medications including a medication reserved for the most severe cases of his medical condition. The discharge planning team had not identified an appropriate treatment option in a less restrictive setting.  This is particularly important as his multiple hospitalizations and recent prompt readmission suggested a similar pattern moving forward in absence of a suitable step-down facility. Subsequently, the patients maintenance dose of medication had been established. He was appropriate in behavior and neither agitated nor disruptive. Further, he was accepted to an appropriate residential treatment program that could admit him. Considering his prompt decompensation that resulted in re-admission quickly after his most recent hospital discharge, retaining this patient at the inpatient level of care until direct disposition to the appropriate facility was in the best interest. In sum, considering the case in its entirety within the context of current practice guidelines and relevant peer-reviewed literature, the acute inpatient psychiatric services were safe, appropriate and consistent with good medical practice and that care could not have been reasonably delivered in a less restrictive setting until direct disposition to the appropriate facility.  Final Result: The reviewer determined that the services at issue were medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned.  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: Overturned

A 55-year-old female enrollee has requested laser treatment for the treatment of her fibrotic lymphedema of the breast and chest. Findings:  Two physician reviewers found that there have been many proposed treatments prescribed and tried for severe secondary upper extremity lymphedema throughout the years, most of these with minimal to moderate satisfactory results. Low-level laser therapy for the treatment of lymphedema has been studied for several years and was cleared by the Food and Drug Administration in 2006 for use to help treat chronic lymphedema. Many patients respond differently to various treatments. When a treatment shows encouraging results, it should be pursued. It has been shown that low level laser therapy is safe and effective. Although long-term data are not yet available, this should not preclude use of this therapy in this case when there is documented evidence that the patient is responding with encouraging results. Low-level laser therapy certainly adds to our armamentarium for treating this debilitating consequence of cancer treatment.
Appeal type: Medical Necessity
Decision: Upheld

A 39-year-old female enrollee has requested for acute inpatient psychiatric services for treatment of her eating disorder and depression. Findings:  The physician reviewer found that no admission psychiatric assessment was provided and there is not a single body weight recorded. The psychiatric notes are insufficient in terms of the frequency of visits, body weight, mental status examination and treatment planning. No documentation of discharge planning is evident via social work notes or notes from other providers. In light of the documented interventions and treatment planning and the patients limited improvement after a month of inpatient psychiatric care, continued treatment in this setting cannot be endorsed.
Appeal type: Medical Necessity
Decision: Upheld

This patient is a 3-year 10-month old female who is the product of a triplet gestation and was born at 35 12 weeks.  She has a history of developmental delay and began receiving occupational therapy (OT) in May 2004. The goals of therapy addressed gross motor skills (including climbing stairs, independently jumping and running) and fine motor skills (visual motor accuracy, visual perceptual skills, motor planning, in-hand manipulation skills and hand strength). The September 2004 report states the patient is independent in self-feeding with a spoon, can pierce food with a fork, and drink independently from a cup. The progress report also indicates work in the area of sensory processing. The patients parent has requested coverage for additional OT and the Health Plan has denied the request based upon their determination that it is not medically necessary.I have reviewed both the July 2005 OT evaluation and the September 2004 OT progress report. Each report stated that the child is delayed in fine and gross motor skills. At age 40 months, the July 2005 report assessed motor skills as significantly delayed with an age equivalency of 23 months. The report however, did not refer to specific areas of the standardized testing that substantiated this assessment.  In fact, in its more detailed description of gross motor skills, which included proprioception and the vestibular system, the report described the patients performance as within normal functional limits for a 3-year 4-month old child.   The reports description of fine motor skills included stringing beads, holding a pencil with tripod grip, stacking 12 blocks, and fastening and unfastening one-inch size buttons.  The patients performance was also within normal limits for this skill set. She is described as being able to make both horizontal marks and vertical strokes but unable to make a plus sign, which is consistent with age appropriate norms.  It is not uncommon for children of multiple births to have some mild motor delays which self-correct within the first five to seven years of life.  The submitted records document no significant motor delays that would require continued therapy.Based upon the information set forth above, I have determined 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: Upheld

A 33-year-old male enrollee requested authorization and coverage of surgical removal of lipomas. The Health Plan denied the request indicating that the requested procedure is not medically necessary for treatment of the enrollees lipomas on his back, flanks, and chest.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 at this time.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a panniculectomy for treatment of the enrollees excess skin status post weight loss surgery. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity for the requested procedure in this clinical setting. The medical literature supports a panniculectomy for treatment of skin redundancy for patients who have experienced massive weight loss. This patient has a history of weight loss status post sleeve gastrectomy. Additionally, the records indicate that this patient has failed conservative treatment for her longstanding rashes including treatment by her primary care provider. A panniculectomy will eliminate the overhanging abdominal skin that predisposes the patient to recurrent skin infections. As such, a panniculectomy with skin resection is sufficient to treat this patients infections and will relieve her functional problems from chronic rashes. Final Result: The reviewer determined that the requested procedure 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 plastic 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 27-year-old male enrollee requested Androgel for medical treatment of his medical condition.  Findings:  The physician reviewer found that the submitted documentation establishes the medical necessity of the requested medication. Wiechno and colleagues assessed the degree of hormonal abnormalities in testicular cancer survivors and the effect of these changes on patients quality of life. The authors concluded that hormonal abnormalities have a negative impact on the quality of life of testicular cancer survivors. In addition, patients treated for testicular cancer have a higher risk of ejaculatory, orgasmic and erectile dysfunctions compared with healthy males (Rosendal, et al). In this case, the patient has a history of testicular cancer with symptoms of decreased libido, weight gain, and decreased energy. The patient has previously been treated with Androgel with relief of symptoms. As such, the patients request for Androgel is medically necessary in this clinical setting.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for prescribed Otezla. The Health Plan has denied this request indicating that the requested medication is not medically necessary. The submitted documentation does not support the medical necessity of the requested medication. The submitted documentation notes the patient has been treated with other medications. However, the medical records fail to indicate a contraindication, adverse effect or failed treatment trial for any of the preferred treatments.Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. There are standard first-line therapies available for treatment of this patients psoriasis, the requested Otezla is not supported as medically necessary. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in dermatology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for venous angioplasty provided for her diagnosis of Paget-Schroetter syndrome.  Findings: Three physician reviewers found that the documentation as well as the literature support the procedure at issue in this clinical setting. The patient was treated for subclavian vein thrombosis with thrombolysis. On follow-up, there was some residual thrombus that was removed and intravascular ultrasound confirmed a tight narrowing in the subclavian vein. The venous angioplasty performed was indicated to prevent recurrent DVT. Therefore, the venous angioplasty performed  was likely to have been more effective than other methods for treatment of this patients medical condition.Final Result: Three reviewers determined that the procedure 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 overturned. Credentials/Qualifications: The three reviewers are board certified in vascular surgery and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 45-year-old female enrollee requested authorization and coverage of gastric bypass with duodenal switch. The Health Plan denied the request indicating that the requested procedure is not medically necessary for the treatment of the enrollees obesity.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.