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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the UroLift procedure. Findings:  The physician reviewers found that the UroLift procedure performed was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. There is sufficient peer-reviewed literature supporting the procedure at issue. Authors of a study performed a systematic review and meta-analysis of reported symptomatic, functional, and sexual outcomes following the prostatic urethral lift procedure. The authors concluded that the prostatic urethral lift procedure is a well-tolerated procedure that produces improvement in urinary symptoms and function while preserving sexual function. In sum, UroLift is a well-tolerated procedure for BPH and provides immediate improvement in obstructive symptoms. All told, the procedure at issue was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: 2 of 3 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 physician reviewers are board certified in urology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested intravenous antibiotic treatment for treatment of her medical condition.  Three physician reviewers found that the services at issue were not likely to be more beneficial for treatment of the patients medical condition than any available standard. The patient does not demonstrate by history or physical exam findings of late stage Lyme disease. There was no present tick bite or rash, and no sequelae that are consistent with Lyme disease. The patients symptoms are non-specific and are generally not consistent with the diagnosis of Lyme disease. In addition, the patients history is inconsistent as multiple antibiotic courses have made little difference in her clinical course. A positive plasmid DNA does not make the diagnosis of active Lyme disease. It may be positive from previous infection but does not correlate with disease activity. In sum, there is a lack of documentation supporting a diagnosis of late stage Lyme disease. Therefore, the services at issue were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: Three reviewers determined that the services at issue were 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: Three reviewers are board certified in internal medicine 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for treatment with a neuropsychiatrist who specializes in traumatic brain injury and long-term care at an inpatient rehabilitation facility that specializes in traumatic brain injury. Findings:  The physician reviewer found that The submitted documentation supports the requested services in this clinical setting. This patient sustained severe traumatic brain injury. The records document attention deficit/hyperactivity disorder and behavioral issues involving agitation. A neuropsychiatrist who specializes in traumatic brain injury is medically appropriate in this patients case. A neuropsychiatrist who specializes in traumatic brain injury will be able perform a complete neurocognitive assessment and provide therapies which may be beneficial for the rehabilitation of this patient. An inpatient rehabilitation facility that specializes in traumatic brain injury is medically appropriate in this case. This treatment setting will allow the patient to improve concentration skills and assist him with difficulties in completing daily tasks. Traumatic brain rehabilitation often involves neuropsychiatrists, psychologists, occupational therapists and physical therapists. Therefore, treatment with a neuropsychiatrist who specializes in traumatic brain injury and long-term care at an inpatient rehabilitation facility that specializes in traumatic brain injury are medically necessary for the 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 neurology 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 46-year-old female enrollee requested authorization and coverage of gastric bypass surgery. The Health Plan denied the request indicating that the requested procedure is not medically necessary for the treatment of the enrollees morbid obesity. One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plans denial on the basis that the requested procedure is medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for cognitive processing therapy (CPT) and eye movement desensitization and reprocessing (EMDR) therapy.In both EMDR and CPT, the life-threatening trauma experienced by the patient is the focus of the therapy with various methods for the patient to re-experience and reframe those traumas. In this case, post-traumatic stress disorder (PTSD) has not been diagnosed by a psychiatrist, although the patient has been diagnosed with major depressive disorder (MDD). Additionally, the psychologist who has been seeing the patient mentions that the patient endorses various trauma-based symptoms but  has not had one big traumatic event. He has experienced a series of events in which hes felt traumatized. The details of the trauma perceived by the patient are not documented, and it seems that the predominant issue causing the patients difficulty in recovering from these experiences are the interpersonal slights he experienced but not specific traumas, and PTSD has not been diagnosed in this patient. Because of this, CPT and EMDR focusing on these traumatic experiences wouldnt be therapeutically indicated more than other psychotherapies based on evidence, and PTSD is the only evidence-based indication for these psychotherapeutic modalities. Therefore, CPT and EMDR 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 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

Nature of Statutory Criteria/Case Summary:  An enrollee has requested breast tomosynthesis for evaluation of her medical condition.  Findings:  Two physician reviewers found that breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. There is sufficient support in the peer-reviewed literature for the services at issue in this clinical setting. According to the study by Ciatto and colleagues, the addition of breast tomosynthesis reduces false positives and increases cancer detection when compared to two-dimensional mammography alone. Moreover, Detection rates, including those for invasive and in situ cancers, were 6.1 per 1000 examinations for mammography alone and 8.0 per 1000 examinations for mammography plus tomosynthesis (Skaane, et al). Given the support above, the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: Two reviewers determined that the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications:  All three reviewers are board certified in diagnostic radiology 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: Upheld

Nature of Statutory Criteria/Case Summary:  The parent of an enrollee has requested tonsil removal surgery for treatment of the enrollees medical condition. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  The provider noted a history of recurrent tonsillitis.  However, there is no documentation of any of these episodes in medical records provided.  In addition, it does appear that this patient has tonsillar hyperplasia, but there is no description of sleep apnea or dysphagia being present.  There is no documented support of a diagnosis of obstructive sleep apnea.  The current medical evidence does not support the requested services in this clinical setting.  All told, the requested tonsil removal surgery is 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 otolaryngology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of a 10-year-old male enrollee has requested authorization and coverage for Nutropin. Applying the American Association of Clinical Endocrinologists (AACE) guidelines for clinical practice for growth hormone use and generally accepted criteria set by the U.S. Food and Drug Administration (FDA) for treatment of short stature with GH therapy, the requested GH therapy is medically necessary. Although this patients pre-treatment height was not below the third percentile, he had a bone age that was ahead of his chronological age, resulting in a poor adult height prediction of 62 inches with the Bayley-Pinneau method. This height prediction is more than two standard deviations below the genetic target height and below the mean U.S. adult male height. Thus, continuation of Nutropin GH therapy 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 pediatrics with sub-specialty 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: Overturned

The parent of a five-year-old male enrollee has requested occupational therapy two days per week for treatment of the enrollees autism. Findings:  The physician reviewer found that children with autism spectrum disorder (ASD), a neurodevelopmental disorder, often require multiple interventions including social play interventions, communication and occupational therapy as noted in the literature by Myers and by National Institute of Mental Health (NIMH). Case-Smith and Arbesman also conducted an evidence-based review of interventions for autism used in or of relevance to OT and offer helpful insight as to the success of the therapy in young patients with autism. Sensory integration is a widely used intervention in occupational therapy. Pfeiffer and Kinnealey presented at the American Association of Occupational Therapy Association in 2008 with findings of their double-blind study that children with autism who received sensory integration therapy through occupational therapy had a modest yet significant decrease in displaying autistic mannerisms. Schaaf and Miller also discuss sensory integration as it is used in occupational therapy practice for young patients with developmental disabilities. Review of the submitted clinical evidence demonstrates this patient is an appropriate candidate for occupational therapy utilizing sensory integration techniques. He continues to have an inconsistent 2-point pinch and other deficits related to his issues with sensory processing. In summary, the available scientific data supports a finding of medical necessity for sensory integration OT therapy for this patient at the requested frequency of twice per week.
Appeal type: Medical Necessity
Decision: Upheld

A 54-year-old male enrollee requested authorization and coverage of an in-home oxygen concentrator for the treatment of cardiovascular pulmonary hypertension.  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 services are not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested vision therapy services. The submitted documentation does not support that the requested services are medically necessary. The field of vision therapy includes many treatments and diagnoses, most of which have not been proven scientifically. This is the conclusion that multiple academic organizations, including the American Academy of Ophthalmology, have reached. In this case, the evaluation of the patient by vision therapy providers has identified numerous ocular abnormalities, but there is little scientific evidence to indicate that these abnormalities are related to the patient's reading problem. The only condition in which vision therapy has been shown to be effective is convergence insufficiency, in which a patient has trouble bringing the eyes close together when they look at near. The submitted documentation in this case includes patient NPC measurements that have not been consistent, and it is unclear whether the patient truly has convergence insufficiency. In the event that it was clearly established that the patient truly had convergence insufficiency, the first step in treatment would be home exercises, such as pencil push-ups, and vision therapy would only be considered if home exercises had not been effective. While the precise nature of the vision therapy being offered is not clear, it may have some benefit for convergence insufficiency only. Under these circumstances, the requested vision therapy is not medically necessary for the treatment of the 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 ophthalmology 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

The patient is a 51-year-old female with a history of optic neuritis in 1978 and subsequent recurring neurological problems. The record indicates she has been seen by several different neurologists over the past six years, and there is disagreement as to a clear diagnosis of multiple sclerosis (MS). The patient has had negative spinal fluid, reportedly normal evoked potentials and MRIs in June 2006 which showed an essentially normal spinal cord and a few small scattered lesions in the deep white matter, not consistent with classic MS findings. The patient has been treated with Rebif for the past year, and until recently, her persistent weakness and unsteadiness have been responsive to treatment with steroids. The patients provider recommended treatment with IVIG and a request for authorization was submitted to the Health Plan. The Health Plan denied the request citing a lack of medical necessity.After a thorough review of the medical records, a diagnosis of clinically definite MS is not clear. Nonetheless, IVIG is not considered a first-line therapy for the treatment of MS. It has been recommended in Germany as a second-line therapy for patients who cannot tolerate interferons and/or glatiramer acetate. In the United States, the FDA has approved several well-studied therapies including Copaxone and Novantrone and it does not appear the patient has had a trial of these medications.  I do not agree that treatment with IVIG is clinically appropriate at this juncture. Therefore, 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 42-year-old male enrollee has requested Oxycontin 80mg, 120 tablets every 30 days for treatment of his pain.   Findings:  The physician reviewer found that review of the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested medication. The medical records fail to document failure of lesser medications to control his pain, which has been rated as low as 2-3/10.  Furthermore, Medications with good evidence of short-term effectiveness for low back pain are NSAIDs, acetaminophen, skeletal muscle relaxants (for acute low back pain), and tricyclic antidepressants (for chronic low back pain) (Chou and Huffman). In the study by Ballantyne and LaForge they state that Opioid therapy for chronic pain has been popularized over the past few decades, and a concern has arisen that the analgesic efficacy of opioids is not always maintained over prolonged courses of treatment despite dose escalation and stable pain. Considering the potentially serious adverse effects of opioids, the idea that pain relief could diminish over time may have a significant impact on the decision to embark on this therapy, especially in vulnerable individuals. The records do not support long-term continued use of this medication for this patient. For the reasons set forth above, Oxycontin is not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for almotriptan malate 12.5 mg tablets, 30 pills every 30 days.  The submitted documentation fails to demonstrate the medical necessity of the requested medication quantity. The treatment of chronic migraine should be centered on prophylactic therapy and lifestyle modification with limitation of acute headache medications. Chronic use of acute migraine therapies predisposes a patient to medication overuse headache. There is evidence to suggest effectiveness of a large number of medications including, but not limited to, topiramate, onabotulinumtoxinA, propranolol, amitriptyline, valproic acid, gabapentin, memantine, zonisamide, and candesartan. Medication overuse headache describes a headache occurring 15 or more days a month and developing as a result of overuse of acute headache medications for an extended period of time. Triptan overuse is one of the most common causes of medication overuse headache. There is a lack of evidence supporting the requested medication quantity in this clinical setting. Therefore, almotriptan malate 12.5 mg tablets, 30 pills every 30 days is not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medication quantity is 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 neurology 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.