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

A 52-year-old male enrollee has requested a power wheelchair for treatment of his hemiplegia.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested equipment in this patients case.  The clinical providers provide inconsistent descriptions of the patients diagnoses and limitations.  Overall, the records indicate that the patient has mild weakness in the upper limbs and moderate weakness in the right lower limb.  However, based on the objective findings in the records, he is able to accomplish his mobility-related activities of daily living using a crutch and a manual wheelchair.  Replacement of his manual wheelchair with a power mobility device for basic mobility would be detrimental to his general health given that manual wheelchair use has been shown to provide significant health benefits over power wheelchair use for individuals with mobility impairments.  The current medical evidence does not support the requested equipment in this setting.  All told, the requested power wheelchair is not medically indicated in this clinical setting.
Appeal type: Medical Necessity
Decision: Upheld

A 59-year-old female enrollee has requested laser skin treatment for treatment of her actinic keratosis.  Findings:  The physician reviewer found that based on review of the available records, the patient is requesting coverage for CO2 laser therapy for destruction of actinic keratoses. She has declined the recommended therapy of 5-fluorouracil cream and photodynamic therapy. She has reportedly been treated with liquid nitrogen therapy in the past without improvement. The use of CO2 laser for the treatment of actinic keratoses is not considered to be first-line therapy. Typical therapies include photodynamic therapy, 5-fluorouracil cream, diclofenac cream, and liquid nitrogen cryotherapy, with relative efficacies published recently (Tzogani, et al). Reports on CO2 laser therapy have demonstrated poor outcomes in patients with actinic keratoses (Fulton, et al). All told, the requested CO2 laser for treatment of actinic keratoses is not medically necessary for this patients medical condition on the basis that proven first-line therapies have not been tried and failed.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 48-year-old man with hepatitis B with precore mutant. A liver biopsy apparently showed stage III fibrosis. It appears the patient has also been treated with lamivudine, developing YMDD mutation. The patient has undergone one year of treatment with Hepsera. A request has been made for continuation of Hepsera. The Health Plan indicates that continuation of Hepsera is not medically necessary.Hepsera has been approved by the Food and Drug Administration for treatment of the patients medical condition. It has been noted that acute exacerbation of hepatitis B is seen after discontinuation of this medication. Multiple studies have shown that Hepsera is a safe and effective treatment for hepatitis B. The consensus among the gastroenterology community is that the duration of therapy should be more than a year. Cessation of therapy should be based upon improvement of the stage of liver disease, development of hepatitis B surface antibody, and elimination of hepatitis B DNA and hepatitis B surface antigen. In light of the clinical information submitted, continuation of Hepsera is medically necessary and indicated for this patient.Based upon the information set forth above, I have determined that the requested medication is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

A female enrollee requested massage therapy services for medical treatment of her lumbosacral radiculopathy status post decompressive lumbar laminectomy. Findings:  The physician reviewer found that formal massage therapy has not been proven in the medical literature to provide marginally significant health or functional benefits in the setting of back pain due to sciatica or radiculopathy over a program of independent exercise and self-administered palliative interventions such as massage using rollers, or passive palliative modalities such as local ice/heat (Furlan, et al). Consistent with these findings, the requested massage therapy services are not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Botox injections. The Health Plan has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees hyperhidrosis of the face and neck. The submitted documentation does not support that the requested services are medically necessary. In this case, the patient is requesting coverage for Botox injections to the forehead for treatment of hyperhidrosis. The patient was previously treated with Botox injections and did not improve, presumably because the dose was too low. As referenced in the medical literature, Botox does not carry an FDA approval for the treatment of hyperhidrosis of the face, only axillary hyperhidrosis. Consequently, the treatment requested is not FDA approved, and it is not clear that the patient has failed therapeutic doses of first line therapies. Under these circumstances, Botox injections are not medically necessary for 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 dermatology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:   An enrollee has requested intensive outpatient services for treatment of his behavioral health condition. Findings:  The physician reviewer found that intensive outpatient services were initially medically necessary for treatment of the patients medical condition, but not thereafter. Given the history provided,  the likelihood of substance use would have worsened without the structure of the intensive outpatient setting to provide support and feedback from peers and therapists. However, subsequently he was described as insightful and knowledgeable about recovery. He was medically and psychiatrically stable and was motivated for recovery. As such, intensive outpatient services level of care was initially medically necessary, after which he could have been treated at outpatient level of care with a concurrent community based support of a 12-step program and a sponsor. Final Result: The reviewer determined that a portion of the services at issue was medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned.  Credentials/Qualifications: The reviewer is board certified in psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a 12-year-old male enrollee has requested for Humatrope growth hormone/Somatropin injections for treatment of the enrollees growth hormone deficiency. Findings:  The physician reviewer found that the predicted adult height is in the normal range and not in the range of FDA approval for the use of growth hormone. In addition, the data does not support that treatment with growth hormone would offer significant additional medical benefit.
Appeal type: Medical Necessity
Decision: Overturned

The patient has requested authorization and coverage for eight weeks of behavioral health intensive outpatient program (IOP) services. Per the American Society of Addiction Medicine (ASAM) criteria, this patient meets level 2.1 criteria for IOP level of care services. The patient meets the criteria for dimensions 3 through 6. For dimension 3, the patient has comorbid depression, anxiety and ADHD. Dimension 4 is met given the patients lack of readiness to change, need for support, and inability to remain sober without structured treatment. The patient is at high risk of relapse. The provider noted that the patient requires support and structure to prevent relapse. The patients living environment provides poor local support and limited coping skills in the setting of isolation. Given that the patient has a high risk of relapse history, legal problems in the setting of his substance dependence, poor functioning, and little local social support, the patient meets the criteria for IOP level of care based on the ASAM level 2.1 criteria. Therefore, the requested eight weeks of IOP services are medically necessary for 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 psychiatry with expertise in addiction 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: 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 the breast tomosynthesis performed on was likely to be more beneficial for evaluation of the patients medical condition than available standard modalities. Although there is a lack of long-term studies demonstrating an increased survival rate when tomosynthesis has been added to the usual screening mammogram films, the addition of the technique has gained worldwide support among providers due to the tomographic properties of the technique which in turn have led to a decrease in callbacks and increase in detection of small cancers. This advantage is due to the ability to largely eliminate the problem of overlying glandular elements which can be confusing to radiologists in the attempt to find subtle areas of mass density or architectural distortion which may in turn be associated with early cancer.  Therefore, in this clinical setting the breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: Two reviewers determined that the diagnostic procedure at issue was 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: Reviewers 1, 2, and 3 are board certified in diagnostic radiology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has been diagnosed with right knee osteoarthritis. The patient noted that a previous right knee viscosupplementation injection provided increased tolerance for activities of daily living and improved sleep. The patient reported right knee pain. The patient has been treated with a home exercise program, an unloader brace, and medication, including ibuprofen and a topical cream. The patient received a right knee cortisone injection. The patient has requested authorization and coverage for Orthovisc injections in the right knee. The Health Plan denied the request and reported the requested services are not medically necessary for the treatment of this patient. At issue in this case is whether Orthovisc injections in the right knee are medically necessary for the treatment of the patients medical condition. Review of the current medical literature pertaining to viscosupplementation reveals mixed results. Although viscosupplementation may relieve knee pain in some patients with osteoarthritis, it is unknown which patients will benefit. Considering the foregoing, viscosupplementation can only be recommended for patients with a history of lasting benefit from prior injections and in carefully selected cases when everything else has been tried and the options are limited. In this case, the patient has a history of benefit from prior viscosupplementation injections. Furthermore, the patients options are limited. The patient has tried and failed other conservative treatments, including nonsteroidal anti-inflammatory drugs, physical therapy, home exercise program, topical analgesics, unloader brace, and corticosteroid injections, with the alternative being a total knee arthroplasty. The medical evidence supports the requested services in this clinical setting. Therefore, Orthovisc injections in the right knee 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 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

Nature of Statutory Criteria/Case Summary:   An enrollee has requested a 12 week course of Harvoni for treatment of his chronic hepatitis C virus genotype 1b. Two physician reviewers found that as per the American Association for the Study of Liver Diseases (AASLD) Infectious Diseases Society of America (IDSA) guidelines, all patients with chronic active hepatitis C are eligible for treatment and should be treated with U.S. Food and Drug Administration (FDA) approved antiviral therapy regardless of fibrosis score. Successful hepatitis C treatment results in sustained virologic response (SVR), which is tantamount to virologic cure, and as such, is expected to benefit nearly all chronically infected patients. Current evidence supports treatment in all hepatitis C virus infected patients, except those with limited life expectancy less than 12 months due to non-liver-related comorbid conditions. The goal of treatment of hepatitis C virus infected patients is to reduce all-cause mortality and liver-related health adverse consequences, including end-stage liver disease and hepatocellular carcinoma, by the achievement of virologic cure as evidenced by an SVR. Therefore, as per the FDA recommendation, the requested Harvoni for 12 weeks is supported as medically necessary for treatment of this patients medical condition. Final Result: Two reviewers 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: All three reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology 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 the enrolle has requested authorization and coverage for the medication Zomacton. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees short stature and history of delayed puberty. short stature is defined as a height that is 2 standard deviations or more below the mean height; for individuals of the same sex and chronologic age in a given population. This translates to a height that is under the 3rd percentile. The most common causes of short stature beyond the first year or two of life are familial (genetic) short stature and constitutional short stature (also known as constitutional delay of growth and puberty); which are normal nonpathologic variants of growth. This patient has no apparent linear deceleration. She has been growing along the 25th percentile as shown on the growth curve. Therefore, abnormal growth is unlikely when a child is growing along her curve. This child had a delayed bone age, which supports the diagnosis of constitutional delay of growth. The estimated predicted adult height based on the bone age is 66 inches, which is within the normal limits for her genetic potential. It is also within the normal limits for an adult female.  Therefore, the requested medication Zomacton is not medically necessary.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 pediatrics with subspecialty 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. Findings:  The physician reviewer found that
Appeal type: Medical Necessity
Decision: Overturned

A 63-year-old male enrollee requested authorization and coverage of a heated humidifier. The Health Plan denied the request.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plans denial on the basis that the requested heated humidifier is medically necessary.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for magnetic resonance imaging (MRI) of the breasts (CPT code 77046). Use of breast MRI is a standard radiologic approach for the evaluation of breast abnormalities of a pathologic nature. Breast MRI is helpful for assessment of breast tumors including metastatic or primary tumors. This patient demonstrates follicular lymphoma status post prior bilateral mastectomy. The provider has recommended further evaluation with breast MRI. Prior evaluation with a positron emission tomography (PET) scan was negative, demonstrating that her follicular lymphoma is PET non-avid. Thus, repeat PET scan would not be of utility for imaging of her breast tumor. MRI has demonstrated superior imaging for PET-negative lymphomas compared to PET and contrast enhanced computed tomography (CT) imaging. Given these findings, the requested MRI of the breast (CPT 77046) is likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Findings:  Three of the three physician reviewers found the requested MRI of the breast (CPT 77046) is likely to be more beneficial for evaluation 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 evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewer 1 is board certified in internal medicine with subspecialty certifications in medical oncology and hematology and is actively practicing. Physician reviewer 2 is board certified in internal medicine with subspecialty certification in medical oncology and is actively practicing. Physician reviewer 3 is board certified in internal medicine with subspecialty certifications in medical oncology and hematology and is actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for the residential treatment center (RTC) services for treatment of the enrollees polysubstance abuse. Findings:  The physician reviewer found that overall, the records provided for review do not support the medical necessity of residential treatment center (RTC) level of care services provided for treatment of this patients behavioral health issues. There were no reports of post-acute withdrawals, the patient did not demonstrate any evidence of suicidal or homicidal ideation, and he had no self-harming behaviors. He was not violent or aggressive and he was not gravely disabled. There were no emotional, behavioral, cognitive, or impulsive symptoms that would warrant treatment at the RTC level of care. He was medically and psychiatrically stable to the extent that he did not require a 24-hour facility to render the remainder of his care. His liver enzymes and medication management could have been monitored on an outpatient basis. There was no evidence of a high degree of depression, mania, hallucinations, or any other significant symptom that would interfere with his care. The psychotic symptoms he presented with on admission were not specifically addressed in the progress notes and were described as likely secondary to schizophrenic spectrum versus substance induced psychosis. The patients bizarre associations were not reportedly addressed. Although verbalizing a desire not to remain in treatment, he was cooperative and participated in his treatment plan. While the patient required ongoing treatment to encourage sobriety, develop coping skills, work on a relapse prevention plan, and work on his relationships and mood lability, none of these were of a severity that required the 24-hour nursing and medical monitoring in a RTC setting. He could have been stepped down to an ambulatory level of care. Final Result: The reviewer determined that the services at issue were 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 with sub-specialty certification in addiction 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.