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

The parents of a nine-year-old male with diagnoses of dystonia and chorea are requesting authorization of a gait trainer with arm prompt set, hip positioner and hip positioner pad.  Reviewers Findings:  The reviewing physician found that the current physical therapy notes show that the patient has not yet achieved functional use of the gait trainer. As such, the gait trainer is currently considered exercise equipment without a clear medical indication.  The reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a female who was diagnosed with an incarcerated umbilical hernia. The patient underwent an emergent incarcerated ventral hernia repair in December. The patient developed recurrence of her hernia in January with an associated small bowel incarceration, requiring a second hernia repair. Mesh was not used in either of the hernia repairs. The patient's body mass index (BMI) was noted to be. At issue in this case is whether hernia repair surgery with mesh is medically necessary for the treatment of this patients medical condition. The incidence of complications with ventral hernia repairs (VHR) increase in obese patients. Elective VHR is not recommended for patients with a BMI of or more. Liang and colleagues noted that mesh reinforcement is recommended for repair of hernias measuring two cm or larger. Further, the authors concluded that there were several areas where high-quality data were limited, and no consensus could be reached, including mesh type, component separation technique, and management of complex patients. There is no evidence that the patient currently has a hernia to support an indication for placing mesh at the site of the previous hernia repair. Therefore, hernia repair surgery with mesh is not medically necessary for 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 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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a 12-week course of home infusions of Gammaplex, dosed at 50 grams per day for three days (150 gram loading dose) followed by 35 grams per day for two days (70 gram maintenance dose) every three weeks. Based on current standards of care, IVIG therapy demonstrates significant efficacy in the treatment of patients with disabling autoimmune forms of dysautonomia. In this case, the patient has a history of chronic inflammatory peripheral neuropathy, commonly caused by autoimmune processes, and has failed conventional treatments. The use of Gammaplex as described in this patients setting is consistent with the current standard of care. Therefore, a 12-week course of home infusions of Gammaplex, dosed at 50 grams per day for three days (150 gram loading dose) followed by 35 grams per day for two days (70 gram maintenance dose) every three weeks is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested treatment 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 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: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for surgery on the left foot heel for treatment of his left heel injury. Findings:  The physician reviewer found that after careful review of the enclosed information and the pertinent guidelines, the requested follow-up left heel surgery for this patient including exploration for foreign body left heel is not medically necessary. The patient has undergone two exploratory surgeries with removal of foreign body. The patient has also had two follow-up x-rays and two MRIs, both of which do not demonstrate retain foreign body or fluid collection. The patient has undergone an extensive work-up by internal medicine, podiatry, and rheumatology including two MRIs and two x-rays, none of which reveal retained foreign body or fluid collection. Final Result: The reviewer determined that the requested surgery 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 podiatry 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 accessories for the power wheelchair, a Standing Seat (E2301) and the Power Seat Elevation System (E2300) for treatment of the enrollees quadriplegia.  The physician reviewer found that power standing is not of proven benefit with respect to health or functional outcomes in the setting of neurological or neuromuscular conditions resulting in standing or ambulatory dysfunction. Currently, there is a lack of high-grade evidence to support that this type of feature improves pulmonary function, circulation, bowel or bladder function, improves muscle function, skin integrity, bony health, or provides other health benefits in patients who are otherwise generally poorly mobile using their own body power. In addition, there is as yet no high-grade evidence to support that use of this type of device reduces osteoporosis or reduces fracture risk to a clinically significant degree in the setting of severe neurological disorders affecting the central nervous system or general health. The records indicate that this patient is at some elevated risk for pressure ulcers due to his condition, but the power standing feature would not be expected to significantly improve his overall risk profile for pressure ulcers. The power standing feature would potentially mitigate risk in some areas, but would also introduce new areas that would be at risk for pressure ulcer development. The patient does not have any documented respiratory impairments or other conditions that would be expected to be improved in any clinically appreciable or health-advantageous manner. The power standing feature is not medically necessary for the requested power wheelchair. With respect to the power seat elevation feature, the patient is already dependent for transfers. Power seat elevation would not increase his mobility or independence. For these reasons, the requested accessories for the power wheelchair, a Standing Seat (E2301) and the Power Seat Elevation System (E2300) are not medically necessary. 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 and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for left knee replacement surgery. The submitted documentation supports the medical necessity of the requested services. Indications for joint replacement surgery generally include failure of conservative treatment, subjective findings of stiffness, nighttime joint pain, minimal pain relief with conservative care, current significant functional limitations, age over 50 years, body mass index less than 40, and weight-bearing x-ray findings of significant osteoarthritis. This patient presents with a history of chronic left knee pain. He has reported functional limitations with activities of daily living. His symptoms and clinical examination findings have been consistent with imaging evidence of severe osteoarthritis. Weight-bearing x-rays of the left knee demonstrated varus alignment, bone on bone findings in the medial compartment, decreased lateral and patellofemoral joint space, subchondral sclerosis, and osteophytes on the distal femur, patella, and tibia. Detailed evidence of long-term comprehensive nonoperative treatment and failure has been submitted. The medical evidence supports the requested services in this clinical setting. Therefore, the requested left knee replacement surgery is 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 orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 34-year-old female enrollee has requested a duodenal switch procedure for the treatment of her morbid obesity. Findings:  The physician reviewer found that the duodenal switch is an appropriate and standard primary treatment of morbid obesity. This patient is super morbidly obese and takes NSAIDs, which in a chronic fashion would generally be a contraindication for Roux-en-Y gastric bypass and can cause marginal ulceration (Felix and colleagues). The duodenal switch maintains the pylorus and therefore there is less risk of marginal ulceration. The duodenal switch is approved by the American College of Surgeons, Society of American Gastrointestinal and Endoscopic Surgeons (SAGES), American Society for Metabolic and Bariatric Surgery (ASMBS) and Centers for Medicare and Medicaid Services for use in the treatment of morbid obesity in the well-selected patient. The procedure has been well-studied with long-term outcomes over 10 years. As with any weight loss procedure, there are associated risks. However, duodenal switch is generally safe and effective. Furthermore, it is well-accepted in the field that for super obese populations, the duodenal switch generally affords the greatest weight loss of any weight loss procedure. All told, the duodenal switch procedure is the most appropriate weight loss procedure in this particular setting.
Appeal type: Medical Necessity
Decision: Upheld

The patient is an eight-year-old male who has been diagnosed as having attention deficit disorder (ADD) and anxiety. The patient has been treated with psychostimulants including Dexedrine and Strattera, and with Provigil since 2004. Dexedrine was discontinued due to side effects, details of which are not provided, and Strattera was discontinued due to non-effectiveness. The patient has undergone SPECT imaging, and has been treated with Provigil since August 2004 with success. The Health Plan has denied authorization and coverage for Provigil on the basis it is not medically necessary for treatment of the patients condition.Review of the pertinent literature concerning the use of Provigil and ADD reveals Provigil is not indicated for children under 16 years of age at this point in time. There are no studies demonstrating its efficacy in ADD, and the off-label use of Provigil for treatment of an eight-year-old patient is not considered standard of care by most practicing child and adolescent physicians in the United States.Furthermore, the attempt to explain the rationale for Provigil in ADD due to frontal lobe findings (hypofrontality) is not specific to ADD; it is a very vague, non-specific finding, which has been observed in a variety of psychiatric disorders. With regard to the SPECT findings of a ring of fire pattern, the SPECT is not considered a prerequisite for the diagnosis. SPECT findings are still investigational and are not widely used in the medical community. Thus, at this point the use of Provigil for ADD in an eight-year-old patient is not considered the standard of care and is not medically necessary. Therefore, the Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for low level laser therapy for lymphedema.  Findings:  The physician reviewer found there is sufficient medical literature supporting the requested services in this clinical setting. Robijns and colleagues examined literature on the effectiveness of LLLT in reducing limb volume and pain in adults with breast cancer-related lymphedema. The authors noted that LLLT increases the lymphatic drainage by stimulating the formation of new lymph vessels, by improving the lymphatic motricity, and by preventing the formation of fibrotic tissue. Similarly, Smoot and colleagues found that LLLT confers clinically meaningful reductions in arm volume and pain in women with breast cancer related lymphedema. In this case, LLLT in combination with the standard treatments the patient has been receiving is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.  Final Result: The reviewers determined that the requested services are 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 physical medicine and rehabilitation with sub-specialty certification in pain medicine and is actively practicing.  Two 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

A 60-year-old female enrollee has requested a home sleep study for the treatment of her sleep apnea. Findings:  The physician reviewer found that the most useful measurement in the sleep study for assessment of severity of a sleep apnea disorder is the apnea hypopnea index (AHI), which is the number of apneas and hypopneas per hour of recorded sleep. During a home study, the actual time of sleep is not documented but is estimated. In regards to home sleep studies, the documentation needed for patient management decisions is not at the level of the standard, generally accepted sleep study.  The services included in a standard sleep study (measurement of stages of sleep, amount of actual sleep, documentation of sleep and position of sleep) are medically necessary for treatment decisions. The absence of these services is a deficiency of the home test that renders this exercise in data collection less useful clinically.
Appeal type: Medical Necessity
Decision: Upheld

A 63-year-old female enrollee has requested monitored anesthesia care provided during a colonoscopy for treatment during her colonoscopy. Findings:  The physician reviewer found that the American College of Gastroenterology states that the use of monitored anesthesia care is medically necessary when there is documentation by the endoscopist and the anesthesiologist that specific risk factors or significant medical conditions are present. These risk factors or significant medical conditions include prolonged or therapeutic endoscopic procedures requiring deep sedation, increased risk for complications due to severe comorbidity and history of anticipated intolerance to standard sedatives. Additionally, patients who are less than 12 years of age, patients who are 70 years of age or older, patients who are pregnant, patients with active medical problems related to drug or alcohol abuse, acutely agitated uncooperative patients and patients at increased risk for airway obstruction due to anatomic variation may require monitored anesthesia care.  The medical documentation indicates the patient had no specific medical comorbidity that necessitated the use of monitored anesthesia care for the elective colonoscopy procedure. The patient was an acceptable and appropriate candidate for moderate sedation to be administered by the endoscopist.  All told, monitored anesthesia care provided during a colonoscopy was not medically necessary for treatment of the patients condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 55-year-old female enrollee has requested vitamin B12 cyanocobalamin injection (J3420) and subcutaneous hormone (estradiol) pellet implantation (11980) for the treatment of her medical condition. Findings:  Three physician reviewers found that this patient has been menopausal since her hysterectomy and removal of her ovaries. She apparently has had some benefit from estrogen replacement therapy, but still reports menopausal symptoms at her visits. The issue here is the choice of medications and the route of delivery. The American College of Obstetricians and Gynecologists and the American Association of Clinical Endocrinologists recognize approved therapies for estrogen replacement. These options include FDA-approved formulations which can be administered via oral, transdermal and vaginal routes. There is no submitted information in the records indicating that any of these formulations have been previously tried in this case. The patient has been receiving subcutaneous estradiol pellet implantations. This treatment is not FDA-approved and has not been studied for safety. It includes compounded formulations that may have erratic absorption resulting in less predictable bio-availability. At this time, there is insufficient peer-reviewed scientific data to support the use of subcutaneous estradiol pellet implantations for treatment of menopausal symptoms. There are other well-established therapies available in this setting. In addition, this patient does not have documented B12 vitamin deficiency; thus the use of B12 injections is not indicated. Furthermore, the use of B12 for the treatment of menopause is not FDA-approved and there is no evidence in the peer-reviewed literature that vitamin B12 injections are indicated for the treatment of symptomatic menopause. As stated above, there are other therapies available in this setting with proven efficacy based on high quality outcome data.
Appeal type: Urgent Care
Decision: Upheld

A 44-year-old female enrollee has requested for emergency services on an emergent basis.  Findings:  The physician reviewer found that no evidence of symptoms concerning for a problem that would have caused a reasonable layperson with this patients condition to believe that without immediate treatment, ones health, body functions, or bodily organs would be placed in serious jeopardy. The patients pain level was reported as a 6 of 10 on the VAS which represents moderate as opposed to severe pain. Though the patient maintains that she was concerned about the possibility of stroke in light of her family history, her symptoms were not such that a prudent layperson would believe he or she was at risk of a stroke. The presence of a bump below the jaw is not generally considered a warning sign of stroke. Further, her vital signs were within normal limits and she denied headache and vision problems. Her pain was limited to the left ear and was noted as moderate. All told, the patients symptoms were not such that a prudent layperson in the patients circumstances would reasonably expect the absence of emergency care to seriously jeopardize his or her health.
Appeal type: Medical Necessity
Decision: Overturned

A female enrollee requested Sovaldi 400mg and ribavirin for medical treatment of her hepatitis C.  Findings:  Two physician reviewers found that per the American Association for the Study of Liver Diseases and Infectious Diseases Society of America, all patients with chronic active hepatitis C are eligible for treatment and should be treated with antiviral therapy regardless of fibrosis score.  Successful hepatitis C treatment results in sustained virologic response and is expected to benefit chronically infected persons.  The goal of treatment of HCV-infected persons is to reduce all-cause mortality and liver-related health adverse consequences, including end-stage liver disease and hepatocellular carcinoma.  Therefore, the requested Sovaldi 400mg and ribavirin are likely to be superior over other treatment options.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  The parent of an enrollee has requested Genotropin growth hormone for treatment of the enrollees medical condition.   Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the requested medication. According to the documentation submitted for review, the patients height is not more than two SDs below the mean for age and gender and her growth factors are normal. In addition, the results of provocative GH testing are normal, and she has no known morphological abnormality of the pituitary gland. Thus, the patient does not have classic GH deficiency. A complete longitudinal growth chart (with weight and height data) was not provided, and the reported growth velocity was not calculated over one year of time. The patients adult predicted height is not short enough to qualify for a trial of GH therapy on the basis of the idiopathic short stature indication (adult height prediction <59 inches in a girl). According to Pediatric Endocrinology Society guidelines, a trial of GH therapy should be approved for children with otherwise unexplained short stature who pass GH stimulation tests but who meet most of the following criteria: height more than 2.25 standard deviations below the mean for age or more than two SD below the mid-parental height percentile; growth velocity <25th percentile for bone age; bone age more than two SD below the mean for age; low serum IGF-1 and/or IGFBP-3; and/or other clinical features suggestive of GH deficiency (Wilson, et al).  This patient does not meet the above criteria. Based on the medical literature cited above and the documentation submitted for review, the request for Genotropin is not medically necessary for treatment of the 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 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.