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

The parent of a 12-year-old female enrollee has requested  for Lupron injections for treatment of her short stature. Findings:  The physician reviewer found that there is little support in the literature for the use of Lupron as an adjunctive means of enhancing final adult height in this population of patients. In a recent consensus statement, Clayton, et al stated, At present, there is no convincing evidence that the addition of GnRH analog treatment [Lupron] to inhibit pubertal progression is associated with additional height gain. Thus, at this time there is inadequate scientific data to establish the usefulness or benefit of Lupron in this setting.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for fertility preservation services for treatment of the enrollees risk for iatrogenic infertility secondary to breast cancer treatment. Findings:  The physician reviewer found that female patients undergoing chemotherapy, surgery and/or radiation treatment for cancer may experience serious gonadotoxicity. The extent of ovarian damage is dependent on the type of treatment as well as the age at the time of treatment. As the treatments for malignancies in females continue to improve their survival rates, increasing numbers of patients may seek preservation of their fertility. Reducing the radiation dose to the ovary by shielding or surgically removing the ovaries from the field of radiation may preserve ovarian function. When patients can delay treatment, embryo and oocyte cryopreservation, utilizing in vitro fertilization techniques, can be offered and are now considered the standard of care. Ovarian stimulation with retrieval and cryopreservation of oocytes and embryos can be performed, with later transfer of embryos to the patient or gestational carrier. If damage to reproductive organs from treatment is likely, cryopreserving gametes, embryos, or gonadal tissue may help to preserve fertility. In addition, in vitro fertilization (IVF) techniques for freezing embryos are well established. The American Society for Reproductive Medicine noted that the most established strategy for preservation of female fertility is for a woman to undergo a cycle of IVF and create embryos for later useEstablished methods of fertility preservation include sperm cryopreservation in men and embryo and oocyte cryopreservation in women. Oocyte cryopreservation for the preservation of fertility in patients undergoing chemotherapy for breast cancer, as in this patient, is within the standard of care. Given that the patient is at risk for iatrogenic infertility due to breast cancer, the fertility preservation services were medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the services at issue were 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 obstetrics and gynecology with sub-specialty certification in reproductive endocrinology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 17-year-old female enrollee has requested acute inpatient psychiatric treatment services for treatment of her behavioral health problems. Findings:  The physician reviewer found that the patient's complex history necessitated her stay for a portion of the requested time.
Appeal type: Experimental/Investigational
Decision: Upheld

A 72-year-old male enrollee has requested VitalStim Therapy for treatment of his dysphagia.  Findings:  Three physician reviewers found that review of the submitted documentation fails to demonstrate that the requested therapy is likely to be more beneficial for treatment of the patients medical condition than standard therapies. There is a lack of medical justification in the peer-reviewed literature for continued VitalStim Therapy treatment as it has not been shown to be more beneficial than conventional speech therapy treatment. The medical literature does show some benefit from VitalStim Therapy treatment for milder dysphagia patients; however, in patients such as this patient with severe dysphagia due to paralysis of vocal cords a difference in functional recovery versus more conservative speech therapy treatment has not been documented  (Shaw et al; Kiger et al). In sum, there is insufficient scientific evidence establishing the efficacy of VitalStim Therapy to support its use in this clinical setting.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a 13-year-old male enrollee has requested speech therapy, 2 times per week for treatment of the enrollees medical condition. Findings:  The physician reviewer found that the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested therapy. Based on the documentation submitted for review, the patient has normal receptive and expressive language. The in-Plan speech therapist assessed his receptive and expressive language as between 13 and 14 years, which is in keeping with his chronological age and his placement in a regular classroom. While his pragmatic language is significantly delayed at the 10-year level, this is suggestive of the communicative disorders of the autistic spectrum, and is typically addressed by modalities such as applied behavioral analysis or group therapy. Although there is extensive medical literature indicating that autistic children can benefit from speech therapy, there is a lack of literature that focuses on the use of speech therapy to address pragmatic speech delays in the autistic population. Thus, given the patients normal expressive and receptive language skills, the medical necessity of the requested speech therapy has not been established.
Appeal type: Medical Necessity
Decision: Upheld

A 55-year-old female enrollee has requested authorization and coverage for referral/laser toenail treatment for treatment her onychomycosis.  Findings:  The physician reviewer found that few studies have been done on the use of lasers in the treatment of onychomycosis. Further, the published trials do not demonstrate the superior efficacy of this modality for treatment of onychomycosis. The standard treatment for onychomycosis is oral Lamisil, which has been shown to be at least 80% effective in managing this condition.
Appeal type: Medical Necessity
Decision: Upheld

This case involves an 18-year-old male with severe short bowel syndrome due to complications of a gunshot wound to the abdomen in November 2004. He is now TPN dependent and experiencing significant complications. The patients treating physicians have recommended a living related small bowel transplant. The Health Plan indicates the requested procedure is not medically necessary and has authorized a cadaveric small bowel transplant for the patient. While a living related small bowel transplant is a reasonable alternative to cadaveric small bowel transplant, there are no scientific data to show that the former is superior to the latter. In fact, there is more risk associated with a living related small bowel transplant than with a cadaveric small bowel transplant. In addition, a cadaveric transplant allows more flexibility with the length of the transplanted intestine. The only potential benefit of a living related small bowel transplant is immediate availability of the bowel for transplantation. However, this is not an emergency situation and there is no shortage of donor small bowel in the United States. Therefore, I have determined that the requested procedure is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

A 59-year-old male enrollee has requested test strips and lancets for a home international normalized ratio (INR) monitor for treatment of his primary hypercoagulable state treated with warfarin. Findings:  The physician reviewer found that the patient will likely require long-term treatment with warfarin anticoagulation due to his history of PE secondary to a hypercoagulable state. The peer reviewed medical literature suggests that home INR monitoring offers several advantages over clinical laboratory testing including more frequent testing and therefore better INR target achievement. As reported by Heneghan and colleagues, data collected on patients conducting in home INR testing reveals significantly fewer adverse events and an overall lower mortality rate due to under and over anticoagulation. Moreover, the Centers for Medicare and Medicaid Services (CMS) guidelines require an integrated home education program for the INR monitor and provide coverage for testing strips and lancets to facilitate appropriate usage of the device. Based on these considerations and the reasonable anticipation that this patient will require for the long-term use of warfarin, the requested equipment is medically indicated and appropriate for monitoring and management of his condition. Therefore, the Health Plans denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested breast tomosynthesis for evaluation of her risk for breast cancer.  Two physician reviewers found that the addition of digital breast tomosynthesis reduces false positives and increases cancer detection when compared to standard two dimensional (2D) mammography. The addition of three dimensional (3D) breast tomosynthesis allows for separation of structures to differentiate architectural distortion from masses and overlapping fibroglandular tissue. Moreover, 3D breast tomosynthesis has been shown to improve patient outcomes in this clinical setting. Thus, 3D 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 services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: All three reviewers are board certified in diagnostic radiology and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 67-year-old female enrollee has requested Supartz injections for the treatment of her knee pain. Findings:  The physician reviewer found that while viscosupplementation is an accepted treatment for osteoarthritis of the knee, patients with radiographic advanced disease with extensive joint space loss are less likely to benefit than those in the earlier stages (Wang, et al.). Furthermore, conservative measures such as NSAID medications, intra-articular steroids, and physical therapy are generally employed prior to the use of viscosupplementation.  In this patients case, there is documentation of x-rays showing severe degenerative changes of osteoarthritis. Additionally, there is no documentation of conservative treatment with medications and injections prior to the request for Supartz injections. All told, the patient is not an appropriate candidate for Supartz injections given the advanced stage of her disease and the absence of documentation of treatment with medications and injections.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 52-year-old female who has had a long-standing history of back spasms. She has been diagnosed with torticollis. The patients provider indicates the patient has been treated with physical therapy, activity restriction, and medications such as oral analgesic, NSAID, and muscle relaxants without improvement. The patients pain management specialist has recommended the patient receive Botox injections at monthly intervals. The Health Plan has determined Botox is not medically necessary for treatment of the patients medical condition.Review of the submitted clinical evidence indicates the patient has not responded to conservative care for diagnosis of torticollis. Her provider has recommended Botox injections for torticollis, which is an accepted and evidence-based approach to treatment of the condition. Treatment with Botox is medically appropriate and indicated for this patient. Though development of antibodies is a possibility with monthly injections, this is not a basis on which to deny the use of Botox at this time. Therefore, I have determined that the requested therapy is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned. The patient should receive a trial of monthly Botox therapy for a three-month period with reevaluation by her treating provider at the end of the three-month period.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Mavyret 100-40 mg, three tablets daily, for eight weeks. Findings:  The physician reviewer found that, according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. The guidelines recommend that all patients should be treated, regardless of fibrosis stage. The guidelines recommend that non-cirrhotic, treatment-naive, genotype 1a patients should be treated with Mavyret for eight weeks. These recommendations are based on multiple randomized clinical trials, and the medication is U.S. Food and Drug Administration (FDA) approved for all patients with chronic hepatitis C, genotype 1 regardless of fibrosis stage. All told, Mavyret 100-40 mg, three tablets daily, for eight weeks is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medication regimen 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 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: Upheld

The parent of a six-year-old male enrollee has requested psychological testing, procedure code 96101 for an evaluation of the enrollees autism. Findings:  The physician reviewer found that psychological testing is considered medically necessary for the purpose of establishing the diagnosis of brain-based disorders and to develop a treatment plan. In the case of this patient, there is no indication in the submitted documentation that the requested testing would alter either the diagnosis or treatment plan. There is a clear and established diagnosis of autism spectrum disorder. In regards to the treatment plan, the patient has been receiving ABA services, speech and occupational therapy and Regional Center services. He is also treated at a private clinic. Possible medication trials have already been recommended. Thus, the submitted documentation does not establish that additional psychological testing would impact this patients existing diagnosis or treatment plan.
Appeal type: Experimental/Investigational
Decision: Upheld

A 39-year-old male enrollee has requested ECG gated CT angiography of the coronary arteries for evaluation of his aortic dissection.  Findings:  Two physician reviewers found that this patient has a descending thoracic aortic dissection, no cardiac symptoms and a recent nuclear stress test that revealed unequivocal ischemia by perfusion scintigraphy.  In this circumstance, if additional evaluation of coronary anatomy were thought to be medically necessary, then invasive coronary angiography would be preferred, due to improved accuracy compared to coronary CT angiography and the ability to intervene with percutaneous revascularization during the same procedure, if clinically indicated.  Current expert consensus guidelines that are endorsed by several national organizations do not consider coronary CT angiography appropriate in patients with unequivocal results on perfusion imaging.   All told, the requested ECG gated CT angiography is not likely to be the most efficacious method of evaluating this patient.
Appeal type: Medical Necessity
Decision: Upheld

A 49-year-old female enrollee has requested Lap-Band surgery (adjustable gastric banding system) for treatment of her body mass index of 34.29.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested procedure in this patients case.  This patient has a reported body mass index of 34.29.  There are no documented chart notes describing prior weight loss efforts.  The medical records do not document the recent completion of a multidisciplinary evaluation with dietary evaluation.  Additionally, there is no documentation of a body mass index of 35 or greater meeting the definition of clinically severe or morbid obesity at this time.  The current medical evidence does not support the requested procedure in this clinical setting.  All told, the requested Lap-Band surgery (adjustable gastric banding system) is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

A 43-year-old male enrollee has requested transcranial magnetic stimulation (TMS) therapy for treatment of his major depressive disorder.  Findings:  The physician reviewer found that the submitted documentation demonstrates the medical necessity of the requested services in this patients case.  The peer-reviewed medical literature has demonstrated positive results for this intervention.  TMS has been endorsed by the American Psychiatric Association for the treatment of individuals with depression.  In this patients case, he has trialed multiple medications, including augmentative strategies.  Additionally, he reportedly has been actively participating in psychotherapy.  Per the current practice guidelines and peer-reviewed medical literature, TMS therapy is medically appropriate in this clinical setting.  All told, the requested TMS therapy is medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for doxycycline IR-DR (Oracea). The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the patients rosacea. The submitted documentation does not support the medical necessity of the requested medication. Per the documentation, a trial of doxycycline IR-DR (Oracea), with some improvement. The record did not indicate that the patient has not tried one topical sulfacetamide-sulfur product and one topical metronidazole product. The medical records indicate that the patient was prescribed Oracea in 2016 and then again in 2018. The medical records do not support the necessity of Oracea over the generic topical agents or generic doxycycline. The records fail to demonstrate a lack of efficacy or intolerance to the preferred agents. Therefore, doxycycline IR-DR (Oracea) is not medically necessary for the 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 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: Upheld

Nature of Statutory Criteria/ Case Summary:  The enrollee has requested reimbursement for intensive outpatient program (IOP) services. The enrollee has a diagnosis of anorexia nervosa with laxative abuse, and a history of anxiety/depression who was admitted to the intensive outpatient program (IOP) level of care. The discharge note indicates her weight was consistent with her goal weight. Findings:  The physician reviewer found that according to LOCUS guidelines, for risk of harm, the enrollees composite score is 14, which correlates with low-intensity community based services. Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in psychiatry and child and adolescent 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 51-year-old female with a history of chronic low back pain, obesity, and behavioral health issues. An epidural injection was ordered by the patients pain management provider and has been scheduled for 5/27/05. The patient has requested authorization for a more immediate appointment for the epidural in order to relieve her pain. It appears the Health Plan recommends the patient comply with previously recommended therapies such as physical therapy, a home exercise program or participation in a weight reduction program prior to the patients scheduled epidural injection. The Health Plans denial should be upheld. The submitted records indicate there are other pain management modalities available to the patient prior to her scheduled appointment.  Furthermore, the Health Plans recommendation that the patient comply with a conservative treatment program prior to her scheduled epidural steroid injection is medically reasonable and appropriate. It appears the patient would also benefit from behavioral health services for treatment of her depression and other behavioral health issues. Based upon the information provided, a more immediate lumbar epidural steroid injection is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

A 47-year-old male enrollee requested authorization and coverage of the medication serostim for the treatment of HIV wasting and lipodystrophy.  The Health Plan denied the enrollees request indicating that the requested medication is not medically necessary.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 for treatment of the patients medical condition.