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

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for Alimentum formula along with PediaSure for treatment of the enrollees medical condition. Findings:  The physician reviewer found that records provided for review document that this patient is dependent upon formula for her nutrition. She has multiple food allergies and oral intolerance, requiring a specific blend of PediaSure and Alimentum to meet her needs. While Alimuentum is not typically considered to be a toddler formula, in combination with PediaSure, which is an age appropriate formula, can provide the nutritional balance that this patient requires. Until she is able to tolerate purees and other foods by mouth in sufficient quantity to allow for growth and development, PediaSure and Alimentum are both medically necessary for treatment of this patients medical conditionFinal Result: The reviewer determined that the requested products 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 pediatrics with sub-specialty certification in pediatric critical care 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 41-year-old male enrollee has requested for the use of Strattice Reconstructive Tissue Matrix  for treatment his recurrent ventral hernia.  Findings:  Three physician reviewers found that this patient had failed treatment with several other procedures including the use of synthetic mesh to repair his abdominal wall.  Strattice type meshes show a superior biocompatibility and are gradually remodeled into the host tissue. The two types of biological meshes are non-cross-linked and cross-linked porcine dermal scaffold. The reasons that the use of biological mesh has become more common and even standard of care in some cases include the following: greater cellular infiltration, extra cell matrix formation, neovascularization, greater resistance to bacteria harboring and less prone to chronic inflammatory responses. Considering this patients history with synthetic type mesh, it was appropriate for the patients provider to use the Strattice product to repair the patients abdominal wall, as it was likely to be more beneficial for this patient.
Appeal type: Medical Necessity
Decision: Upheld

A 48-year-old male enrollee has requested  Victoza (3 pak) for treatment of his type 1 diabetes. Findings:  The physician reviewer found that according to the American Association of Clinical Endocrinologists (AACE) guidelines, the use of Victoza is not indicated for use in type 1 diabetes mellitus. In addition, the guidelines note that Victoza is not U.S. Food and Drug Administration (FDA) approved for this indication. Currently, there is a lack of randomized prospective studies demonstrating the efficacy or safety of use of Victoza in type 1 diabetes mellitus. Therefore, the records provided for review do not support the medical necessity of the requested Victoza for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 41-year-old female enrollee requested authorization and coverage of Pegasys and ribavirin therapy. The Health Plan  denied the request indicating that the requested therapy is not medically necessary for treatment of the enrollees hepatitis C.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plans denial on the basis that the requested therapy is medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for deep brain stimulation (DBS). The records provided for review document that this patient is status post two invasive surgical procedures in an attempt to make her a suitable candidate for resection of a seizure focus and she has failed to respond adequately to medical therapy. Based on the records reviewed, the patient is a candidate for two standard surgical interventions for her medically refractory epilepsy with either responsive neurostimulation or vagal nerve stimulation. However, there is a lack of data supporting a role for DBS for treatment of this patients medically refractory epilepsy. Moreover, the current medical literature does not support a role for DBS in this clinical setting over standard neurosurgical therapies including responsive neurostimulation and vagal nerve stimulation. All told, the requested DBS is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: Two of the three reviewers determined that the requested services are 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:  One reviewer is board certified in neurological surgery and is actively practicing. One Reviewer is board certified in neurological surgery and is actively practicing.  One Reviewer is board certified in neurological surgery and is 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

The patient is a 14-year-old male who was seen by a rheumatologist for bilateral patellofemoral syndrome, limb length discrepancy, and flexible painful pes planus. The patient has a history of knee arthralgia. The patient also experiences lower back pain and bilateral plantar calcaneal pain with activity. A request has been made for custom orthotics. The Health Plan has denied the request on the basis that the requested equipment is not medically necessary.Review of the submitted medical records does not demonstrate the need for custom-molded orthotics. The submitted documentation shows the patient has a limb length discrepancy but no modification reflecting that fact is noted on the orthotic prescription. The records indicate heel pain but it does not appear that x-rays were obtained to rule out any bone pathology. Although the patient has a pes plano valgus foot structure the submitted information does not demonstrate that standard orthotics have been tried. Furthermore, there is no record of any posting instructions to compensate for any subtalar valgus. Based upon the information set forth above, I have determined that the requested equipment is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

A 63-year-old female enrollee has requested cone beam tomography for evaluation of her history of temporomandibular joint pain and stiffness. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  In this patients case, physical therapy has been prescribed.  The medical records note clicking in the temporomandibular joint upon opening.  Cone beam tomography may be used to diagnose disc displacement, a condition which would produce the temporomandibular clicking on opening, or arthritic changes, which are often a cause of the crepitus observed in the joints.  However, there is no treatment plan provided other than the description of temporomandibular joint discomfort, and there is no rationale given for cone beam tomography.  The requested cone beam tomography would typically be used to confirm the working diagnosis given.  There is no indication that results of the tomographic imaging requested would alter the course of treatment.  All told, the requested cone beam tomography is not medically indicated for the evaluation of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

A 40-year-old-female enrollee requested authorization and coverage of uterine artery embolization (UAE). The Health Plan denied the request indicating that the requested therapy is considered experimental for treatment of the enrollees uterine fibroids.Three physician reviewers performed an experimental/investigational Independent Medical Review. All three physician reviewers concluded that the requested therapy is not likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy. Because all three physician reviewers concluded that the requested therapy is not likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy, the Health Plans denial has been upheld.
Appeal type: Medical Necessity
Decision: Overturned

An 85-year-old male enrollee requested for skilled nursing and rehabilitation services for treatment of his knee amputation.  Findings:  The physician reviewer found that his family has indicated they do not wish to care for him at home so he has no competent and committed care givers at home.  It is reasonable and medically indicated for him to receive skilled physical therapy and likely occupational therapy as well.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage of Vemlidy 25 mg tablets. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees hepatitis B virus. Findings: The physician reviewer found that the guidelines for the treatment of hepatitis B from the American Association for the Study of Liver Diseases (AASLD) recommend entecavir and tenofovir compared with alternatives for the treatment of chronic hepatitis B. In comparison with tenofovir disoproxil fumarate (Viread), which the patient is taking, the Vemlidy formulation of tenofovir is effective for treatment of hepatitis B but is associated with lower incidence of side effects such as osteopenia and renal disease. Moreover, the patient has demonstrated nausea with Viread. For these reasons, Vemlidy 25 mg tablets is medically necessary for the treatment of this patients hepatitis B. 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 internal medicine with sub-specialty certification in gastroenterology 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 64-year-old male enrollee requested authorization and coverage of continued skilled nursing facility (SNF) services. The Health Plan denied the request indicating that the requested services are not medically necessary for treatment of the enrollees medical condition.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plans denial on the basis that the requested services are medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: A parent of an enrollee has requested authorization and coverage for wheelchair accessories (deluxe canopy (K0108) and under seat storage basket (K0108) for the patients already approved pediatric wheelchair).At issue is whether the requested wheelchair accessories (deluxe canopy (K0108) and under seat storage basket (K0108) for the patients already approved pediatric wheelchair) are medically necessary to treat the patients condition for any of the following: to prevent disease, disability, and other health conditions or their progression; to prolong life; to promote physical and mental health and efficiency; to correct or ameliorate any physical or behavioral conditions.Seating mobility devices are indicated for children who have limited ambulation. In this case, this patient has no structural musculoskeletal impairment or severe functional deficit that would limit his dynamic weight shifting in his current device. His position can be actively and passively changed to accommodate environmental factors. He does not have fixed deformities or pain to prevent this accommodation. Furthermore, these devices are not necessary for safe transportation. Current quality evidence does not support the use of the canopy and under storage basket in this case since they are not medically necessary to treat the patients condition for any of the following: to prevent disease, disability, and other health conditions or their progression; to prolong life; to promote physical and mental health and efficiency; to correct or ameliorate any physical or behavioral conditions.Final Result: The reviewer determined that the requested equipment 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 subspecialty certification in pediatric rehabilitation 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 63-year-old male enrollee has requested Cialis 20mg, once every three days for the treatment of his erectile dysfunction. Findings:  The physician reviewer found that the issue at stake in this case is not regarding the medical necessity of the drug, but rather the quantity of medication that is being requested (one 20mg tablet every three days) versus the quantity that is already approved by the Health Plan (six 20mg tablets per month). The current prescribing limit of six tablets per month by the Health Plan is standard in the medical field and therefore is medically appropriate.
Appeal type: Medical Necessity
Decision: Upheld

A 56-year-old female enrollee has requested for Aciphex 20mg for treatment of her gastroesophageal reflux disease (GERD).    Findings:  The physician reviewer found that proton pump inhibitors (PPIs) continue to be the backbone of therapy to fight acid suppression, providing excellent relief of symptoms and healing to erosive as well as non-erosive esophagitis. For the most part, all PPIs are equivalent in their efficacy to control acid secretion. Inter-patient variability of the efficacy has been seen. However, milligram for milligram, all drugs in this class appear comparable in their effects clinically as human studies have not revealed significant or differences in their effects with regards to clinical or endoscopic end points or side effects profile.
Appeal type: Medical Necessity
Decision: Upheld

A 53-year-old female enrollee has requested weekly individual counseling sessions for treatment of her attention deficit/hyperactivity disorder, impulsive type and major depression, recurrent.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  The medical records do not document the need for weekly psychotherapy.  The patient was not attesting to suicidal ideation.  She is not a danger to self or others.  She is able to care for herself and her children.  While the patient and others report that she currently feels overwhelmed, there is no further delineation of what symptoms or behaviors she is actually experiencing or showing.  The documentation does not indicate that attempting a lower level of care will cause the patient to imminently decompensate.  In this patients case, outpatient psychotherapy sessions at a frequency of every other week are medically appropriate.  All told, weekly individual counseling sessions from the specified date forward were not and are not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

A 52-year-old female enrollee has requested Ambien and Ativan for treatment of her bipolar disorder. Findings:  The physician reviewer found that the current available literature does not support the use of long-term benzodiazepines in the management of bipolar disorder. Mood stabilizers, including: lithium carbonate, lamotrigine and Depakote are considered to be the mainstays in the treatment for bipolar disorder. Concomitant use of atypical antipsychotics or benzodiazepines is only warranted during an acute manic phase. Ativan has been shown to be effective in the treatment of acute primary or secondary mania but has no clinical role in long-term treatment. This patients clinical records do not reflect any episodes of acute mania. The patients secondary diagnosis of anxiety/panic disorder can be effectively treated with alternative FDA approved agents. While this patient requires further treatment for her diagnosed conditions, the alternative services offered by the Health Plan are medically reasonable and appropriate. Therefore, the requested medications are not medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 64-year-old male enrollee has requested for robotic assisted physical therapy and robotic assisted occupational therapy for treatment of his hemiplegia.  Findings:  Three physician reviewers found that the peer-reviewed medical literature has shown the use of robotic assisted therapies to be promising, there is not yet compelling evidence that the application of this technology is superior to traditional physical and occupational therapy. Specifically, Marchal-Crespo and Reinkensmeyer state it is still unclear whether robotic control approaches have the potential to produce greater benefit than is possible with simpler techniques such as rote, unassisted practice. The authors go on to conclude that randomized, controlled trials in the field utilizing comparison of control algorithms with each other and with simpler, non-robotic therapy approaches still need to be conducted. All told, there is insufficient data demonstrating that the requested robotic assisted physical therapy and robotic assisted occupational therapy is likely to be more efficacious for this patient than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld

The parents of a 16-year-old male enrollee have requested for growth hormone therapy for treatment of the enrollees isolated growth hormone deficiency. Findings:  The physician reviewer found that it would seem that the patient had some delayed maturation with a pre-medication adult height close to the mid-parental target. As the patient likely would have been close to mid-parental height without therapy, there is no indication for growth hormone therapy. In addition, the lack of IGF-1 and IGFBP-3 does not assist in establishing a need for growth hormone therapy.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for hydrocodone. Medical guidelines require regular checks of the prescription drug monitoring system and utilization of urine drug testing as part of chronic opioid therapy. This patients provider generated a CURES report and confirmed that the patient has been receiving prescriptions of hydrocodone from his previous provider. A urine drug screen demonstrated nor-hydrocodone in the urine, which is consistent with regular usage of hydrocodone. Moreover, the requested medication is consistent with medical guidelines, which state that providers should continue opioid therapy only if there is clinically meaningful improvement in pain and function that outweighs risks to patient safety. The providers notes do not document any drug seeking behavior or concern that the risks associated with opioid therapy outweigh the possible benefits. The primary reason for the Health Plans denial of the hydrocodone is due to a lack of documentation that the patient has been receiving chronic opioid therapy. The CURES report generated by the provider shows that the patient has been receiving hydrocodone from the same provider without interruption. Based on the available records for review and the current guidelines, the requested hydrocodone is medically necessary for treatment of this patient. 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 anesthesiology with subspecialty certification in pain management 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 authorization and coverage of a power-operated vehicle (POV) for the treatment of deteriorating osteoarthritis in knee.  The health plan denied the enrollees request indicating that a POV 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 equipment is not medically necessary.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:   The parent of an enrollee has requested the RT300 functional electrical stimulation (FES) cycle rehabilitation system for treatment of the enrollees unilateral upper extremity paralysis.  Two physician reviewers found that the equipment at issue was likely to be more effective for this patient than other available treatment options. Functional electrical stimulation (FES) of the central and peripheral nervous system can use these intact neuromuscular systems to provide therapeutic exercise options to allow functional restoration and to manage medical complications following SCI. The use of FES for the restoration of muscular and organ functions may significantly decrease the morbidity and mortality following [spinal cord injury] SCI. According to the documentation submitted for review, the patient presents with a spinal cord injury secondary to transverse myelitis. There is support in the peer-reviewed literature demonstrating improvement in motor and functional parameters. Therefore the FES cycle rehabilitation system was clinically indicated for treatment and likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.   Final Result: Two reviewers determined that the equipment 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: One reviewer is board certified in child neurology and is actively practicing. One reviewer is board certified in neurology with special qualification in child neurology and is actively practicing.  One reviewer is board certified in pediatric rehabilitation medicine and is 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.