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

The parent of a two-year-old female has requested approval for brace therapy for treatment of her internal femoral position.   Findings:  The physician reviewer found that based on review of the available records, it is not medically necessary for this patient to have bracing therapy with orthotics to treat the tibial and femoral torsion noted to be present by the provider. The medical literature indicates that special shoes, casts, or braces, in patients with intoeing and tibial and femoral torsion do not result in substantial improvement. The criteria for patients requiring surgical osteotomy and derotation are specific and are not applicable to a two-year-old patient. Further follow-up and documentation of rotational deformity through specific angular measurements may be indicated, but the use of bracing therapy with orthotics is not medically necessary for this patient.
Appeal type: Medical Necessity
Decision: Upheld

A 20-year-old female enrollee has requested breast reconstruction with submuscular implants for treatment of her hypomastia. Findings:  The physician reviewer found that tuberous breast syndrome is characterized by a constricting ring at the base of the breast, which leads to deficient horizontal and vertical development of the breast with or without herniation of the breast parenchyma toward the nipple areolar complex and areola enlargement. This patient has enlarged areola and vertical deficiency below the nipple level. Tuberous breast syndrome is classified into four types. These types range from Type I, which involves hypoplasia of the lower medial quadrant, to Type IV, which is characterized by severe breast constriction, minimal breast base, and herniation of breast tissue into the nipple areolar complex. In this patients case, she has Type I tuberous breasts as the side view photograph demonstrates adequate lower outer quadrant tissue, especially on the left side. Type I tuberous breasts is considered a normal variant of breast appearance and within the range of accepted variations. Therefore, the patients condition does not constitute an abnormal structure of the body and does not meet criteria for reconstructive surgery. Further, breast reconstruction with submuscular implants is not medically necessary for the patients medical condition. The requested surgery is not being performed to improve function, as there is no functional deficit.  All told, the requested breast reconstruction with submuscular implants is not reconstructive in nature and is not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested laparoscopic hysterectomy for treatment of the enrollees medical condition.  Findings: The physician reviewer found that this is a patient who has well documented history of severe dysmenorrhea that has not responded to conservative measures such as oral contraceptives and pain medications. Per the patients provider, palpation of the uterus produced pain. There is no evidence of endometriosis on laparoscopy. There is a fibroid but it is small and unlikely to be the cause of her pain. Degeneration could cause acute pain, but this would not explain her years of pain.  The small ovarian cyst is likely functional and also would not cause the pain at issue.  The cyclic nature and lack of bowel or bladder symptoms make gastrointestinal or urologic causes remote. A more likely diagnosis is either severe dysmenorrhea, and/or adenomyosis, both of which, will respond to hysterectomy. Adenomyosis is often diagnosed in women at the end of their reproductive years, is frequently associated with the presence of fibroids, and the diagnosis is only definitively made on microscopic examination of the uterus after hysterectomy. In sum, the pattern and location of the pain makes it likely that the pain is uterine in etiology and that removal of the uterus would likely resolve the patients issues. For all these reasons stated above, the requested laparoscopic hysterectomy is medically necessary for treatment of this patients medical condition.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 physician 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  The representative of an enrollee has requested the Novo-TTF device for treatment of the enrollees medical condition.  Three physician reviewers found that the Novo-TTF is a novel portable medical device that generates low-intensity alternating electric fields, that was approved by the U.S. Food and Drug Administration for use in the treatment of glioblastoma..  In the study by Stupp and colleagues, 237 patients with recurrent glioblastoma were randomized either to chemotherapy or Novo-TTF therapy.  There was no difference seen in overall survival between the chemotherapy group and the Novo-TTF group.  However, there was noted to be significantly less toxicity in the Novo-TTF group.  All told, the Novo-TTF device was likely to have been more effective than other treatment options. Final Result:  Three reviewers determined that the device 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: All three reviewers are board certified in internal medicine with sub-specialty certification in medical oncology 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 patient has requested authorization and coverage for Entresto 24-26 mg tablets two times daily. Based on the records provided for review, this patient has severe coronary disease and a reduced left ventricle ejection fraction (LVEF) of 25% in the setting of acute coronary syndrome prior to coronary revascularization with coronary artery bypass graft (CABG) surgery. There is no documentation that the patient continued to experience heart failure with a severely reduced LVEF of 40% or less postoperatively. Entresto is U.S. Food and Drug Administration (FDA) approved for the treatment of patients with chronic heart failure and reduced LVEF. In this patients clinical circumstance, the medical records do not support an indication for Entresto in the absence of documentation of either congestive heart failure or reduced LVEF of 40% or less post coronary revascularization. For these reasons, the requested Entresto 24-26 mg tablets two times daily are not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested medication 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 internal medicine with subspecialty certification in cardiovascular 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: Medical Necessity
Decision: Upheld

The patient is a 53-year-old man with dementia who failed treatment at a board and care facility due to decreased insight and an inability to perform activities of daily living. The patient was stabilized in an inpatient psychiatric unit and was discharged on 12/17/02. The patient was immediately re-admitted on an involuntary hold reportedly due to advanced disability and an inability to accept help. A request has been made for reimbursement for acute psychiatric treatment services received from 12/17/02 through 1/3/03.During the period in question, the patient had placement issues due to a failed stay at a board and care facility. Review of the submitted clinical records indicates that as of 12/17/02, the patient did not have psychiatric issues and did not pose a threat to others. Furthermore, the patient was not a threat to himself from a psychiatric standpoint, but rather, was at risk due to an inability to perform activities of daily living. As such, he did not require acute psychiatric care during the period in question. Therefore, I have determined that the services at issue were not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

A 60-year-old male enrollee has requested an additional six tablets per month of Cialis 20mg. for treatment of his erectile dysfunction. Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the requested medication quantity.  The Health Plan has agreed to provide coverage for six tablets of Cialis 20mg per month.  This is an appropriate quantity of this requested medication.  There is a lack of support for the requested total of 12 tablets of Cialis 20mg per month.  Per the current medical evidence, six tablets per month of Cialis 20mg is an appropriate quantity.  All told, the requested additional six tablets per month of Cialis 20mg are not medically indicated in this clinical setting.
Appeal type: Medical Necessity
Decision: Overturned

A 42-year-old female enrollee requested authorization and coverage of right breast reduction mammoplasty. The Health Plan denied the request indicating that the requested procedure is not medically necessary for treatment of the enrollees breast asymmetry.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: Overturned

A 33-year-old male enrollee has requested a consultation with a dermatologist for treatment of his scalp disorder. Findings:  The physician reviewer found that this patient has been referred by his primary care physician to a dermatologist for evaluation and treatment of a scalp condition that has not responded to treatment.  The Health Plan has denied this request on grounds that it is not medically necessary because the primary care physician has not tried conservative therapies or a skin biopsy.  The primary care physician does appear to have tried conservative therapies (Nizoral shampoo) within his knowledge base.  Primary care physicians should not be performing scalp biopsies, as this is outside the scope of the training of an internist and likely is not needed in the diagnosis of this condition.  Seborrheic dermatitis often requires the combination of treatment with antifungal shampoos and topical steroids, as noted by Elewski and Shin and colleagues.  This patient should be evaluated by a dermatologist to rule out other causes, including scalp psoriasis or tinea capitis.  The patient has had an adequate treatment period to have seen improvement.  A consultation with a dermatologist is medically indicated in this patients case.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Percocet or Norco for treatment of her medical conditions.  Findings:  The physician reviewer found that in the medical literature, Felicilda-Reynaldo discussed opioid risk mitigation tools that are part of standard practice. The author noted that when patient safety issues are identified such as lack of compliance, lack of adherence to prescription, or aberrant use, opioids should not be continued. Cheung and colleagues indicated that opioids are generally not recommended as first-line therapy. In addition, the authors reported that opioids should be tapered when patient safety risks are identified. Overall, the peer-reviewed guidelines support use of opioids with ongoing review and documentation of pain relief, functional status, appropriate medication use, and side effects. The medical records in this case report chronic pain. All told, the documentation provided for review does not support the medical necessity of the requested Percocet or Norco for treatment of this patients chronic pain.Final Result: The reviewer determined that the requested medications 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 neurology 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

An enrollee has requested authorization and coverage for penciclovir topical (Denavir) 0.5 mg. The patient notes that when she has herpetic outbreaks, she is treated with oral valacyclovir as well as the topical treatment. Oral valacyclovir effectively penetrates the tissues of the nasopharynx and is formulated to reduce the number of recurrent lesions and decrease the duration of pain. Overall, there is a lack of support for use of an additional topical agent with oral valacyclovir. Accordingly, the requested penciclovir topical (Denavir) 0.5 mg is not medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the requested medication 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 internal medicine with sub-specialty certification in infectious 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: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: enrollee has requested authorization and coverage for Valcyte (450 milligram twice daily); laboratory testing complete blood count with differential, performed every three weeks for the first four months, then every six weeks thereafter; and laboratory test metabolic panel, comprehensive performed every three weeks for the first four months, then every six weeks thereafter for treatment of the enrollee who has a history of chronic fatigue syndrome. Findings:  The physician reviewer found that While there has been interest to link chronic fatigue syndrome to a viral infection, there is a lack of evidence to support this theory. The studies available are small and have shown only limited benefit to the treatment of chronic fatigue syndrome patients with antiviral agents.  In this patients case, the patient had elevated antibody levels to several herpes viruses.  However, these are common infections and observation does not imply any causal relationship between herpes and chronic fatigue syndrome. Moreover, the requested treatment option is not accepted as community standard and not supported by any solid medical evidence. For these reasons, Valcyte (450 milligram, twice daily); laboratory testing complete blood count with differential, performed every three weeks for the first four months, then every six weeks thereafter; and laboratory test metabolic panel, comprehensive performed every three weeks for the first four months, then every six weeks thereafter, 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 internal medicine with sub-specialty certification in infectious 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: Medical Necessity
Decision: Upheld

A 39-year-old female enrollee has requested transcranial magnetic stimulation (TMS) for treatment of her behavioral health condition.  Findings:  The physician reviewer found the submitted documentation fails to demonstrate the medical necessity of the requested therapy. TMS is approved by the U.S. Food and Drug Administration (FDA) for treatment of major depressive disorder. Moreover, the American Psychiatric Association (APA) has endorsed TMS for the acute phase treatment of major depressive disorder. However, the recommendation does not extend to bipolar disorder. Although some preliminary positivism can be found in the medical literature regarding the application of TMS therapy for the bipolar population, the safety and appropriateness of TMS for this indication remains unclear. Given the lack of scientific evidence supporting the use of TMS therapy in this clinical setting, the medical necessity of TMS therapy for treatment of the patients medical condition has not been established.
Appeal type: Medical Necessity
Decision: Overturned

A 53-year-old female enrollee has requested Lyrica for the treatment of her lumbar radiculopathy. Findings:  The physician reviewer found that this patient has a persistent neuropathic pain (PHN) syndrome, with neuropathy versus radiculopathy. PHN and diabetic neuropathy are often the best studied conditions with new medication for neuropathic pain, due to their relatively high prevalence and thus ease of study. Medications useful for treatment of diabetic polyneuropathy are often useful for treatment of neuropathic pain from other causes, such as radiculopathy. A literature review documents the broadly useful profile of Lyrica for neuropathic pain, even beyond the FDA indication. This patient has tried and failed standard treatments for neuropathic pain. She has, however, had successful treatment with Lyrica with improved pain and good tolerance. Lyrica is more likely than standard alternatives to benefit this patients neuropathic pain, and is medically necessary for management of her condition.
Appeal type: Medical Necessity
Decision: Upheld

An enrollee has requested authorization and coverage for physical therapy visits (50 minutes total treatment time, including 40 minutes of direct contact with the patient, twice a week for 6 weeks). A review of the medical literature reveals that studies to date have not found one exercise regime to be superior to another after a total knee replacement. The literature reveals that physical therapy interventions show short-term improvements in physical function and that there are limited studies that indicate that there are long-term benefits of physiotherapy or exercise interventions after a total knee replacement. The literature does not support that one therapy is more beneficial than another. In this case, the patient has been offered continued physical therapy and she has also been trained in a home exercise program. The documentation and literature do not support that the requested frequency, duration and format of physical therapy (50 minutes total treatment time, including 40 minutes of direct contact with the patient, twice a week for 6 weeks) are medically necessary after total knee replacement. 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 physical medicine and rehabilitation, with subspecialty certification in neuromuscular 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 physical therapy for treatment of her cervical radiculopathy.   The physician reviewer found that based on the clinical documentation submitted for review, the medical necessity of physical therapy has not been established. The study by Fritz and colleagues found that the addition of traction to exercise therapy improves clinical outcomes. In this study the subjects had four weeks of treatment and showed continued benefit a year later. Thoomes and colleagues conducted a systematic review of conservative care for cervical radiculopathy, concluding that On the basis of low-level to very low-level evidence, no 1 intervention seems to be superior or consistently more effective than other interventions. Regardless of the intervention assignment, patients seem to improve over time, indicating a favorable natural course. In this case, the patient has had extensive physical therapy with recurrent weakness and pain. She complains of symptoms such as returning/worsening pain when she is not in physical therapy. Based on the patients initial onset of symptom and recurrence of symptoms, additional physical therapy as a form of conservative care is not supported as medically necessary.  Final Result: The reviewer determined that the requested therapy 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 physical medicine and rehabilitation with sub-specialty certification in neuromuscular 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.