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

A 63-year-old female requested authorization and coverage for a referral to an out-of-plan provider for surgery. The health plan denied the request, indicating that the requested referral to an out-of-plan surgeon is not medically necessary, because there are in-plan providers who are experienced in thorascopic resection of lung tumors and mediastinal nodes who can treat the enrollee.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the health plans denial on the basis that the plan has demonstrated that it has in-plan thoracic surgeons who can provide the medically necessary services required by the patient.
Appeal type: Experimental/Investigational
Decision: Upheld

A 58-year-old male enrollee has requested Microvolt T-wave Alternans testing for evaluation of his risk for coronary artery disease. Findings:  Three physician reviewers found that Microvolt T-wave alternans testing is a modality that examines the microscopic changes in the repolarization of the heart (T-wave) on an electrocardiogram (EKG). This testing has been investigated as a tool to refine the risk prediction of those that meet criteria for placement of an implantable cardioverter defibrillator (ICD). Thus far, there has been a paucity of data to support its role in predicting potentially fatal events in patients with systolic dysfunction. This patient presents with reportedly normal systolic function. In addition, due to lack of documentation from the treating provider as to the indication for the Microvolt T-wave alternans testing, there is insufficient justification for use of this testing over standard testing. In conclusion, from the available data it appears that there is no conclusive and evidence-based medical indication for the Microvolt T-wave alternans testing in this patient.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:   An enrollee has requested a seat lift for treatment of her medical condition.  Findings:  The physician reviewer found that the current medical evidence does not support the requested equipment in this patients case.  The natural history of multiple sclerosis is typically a relapsing and remitting pattern.  During this period, exercise to improve fatigue, mobility and quality of life is considered an important component of disease management.  In this case, the records indicate that the patient has an end-stage form of progressive multiple sclerosis, with various impairments including visual, cognitive and motor impairments.  The available records do not establish that the patient is able to ambulate safely.  She has a wheelchair, and there are no indications that the patients wheelchair does not meet her seating and mobility needs.  The requested equipment is not medically necessary for the patients mobility-related activities of daily living.  All told, the requested seat lift is not medically indicated for the treatment of this patient. 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: Upheld

A 44-year-old male enrollee has requested for mole removal for treatment of his mole between his eyes. Findings:  The physician reviewer found that there is no evidence of irregular pigmentation, irritation or bleeding of the lesion. Additionally, there are no documented concerning features of malignancy with the lesion, as the mole is not inflamed, bleeding, or otherwise causing adverse symptoms which would necessitate removal of the benign lesion.  Removal of the mole would be considered cosmetic in this location.  All told, removal of the mole is not medically necessary and the Health Plans denial was appropriate.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for a shoe lift (L3310 x 3 lift elevated heel and sole neoprene inch up to eight in one year). Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested equipment. Russell-Silver Syndrome is a disorder resulting from an abnormality in an imprinted gene. Neonates may present with intrauterine growth retardation. There are characteristic facial features, including broad prominent forehead, triangular shaped face, and downturned mouth. Affected children may also have leg length discrepancies, developmental delay, hypoglycemia, and diaphoresis. In this patients case, he is at risk for complications from leg length discrepancy, including pain, inflammation, ambulation difficulties, and scoliosis. Without surgical intervention, in order to ambulate independently, this patient requires shoe lifts which are custom fitted and attached to his shoes. Without the lifts, he is unable to participate in appropriate activities of daily living. Custom shoe lifts are medically indicated until such time that his leg length discrepancy has been surgically corrected. All told, the requested equipment is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested equipment 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 pediatrics 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 two-year-old male enrollee has requested a humidifier and purifier for treatment of the enrollees bronchitis, asthma and allergic rhinitis.  Findings:  The physician reviewer found that based upon a review of the information provided and the evidenced-based data reviewed for the management of childhood asthma, there is no indication to support the use of a humidifier as a treatment for asthma. The guidelines published by the National Heart, Lung, and Blood Institute do not recommend the use of humidifiers and evaporative (swamp) coolers in homes of patients who have asthma and are sensitive to house-dust mites or mold. In addition, the National Environmental Education Foundation noted that mold has been found in humidifiers and for this reason are not recommended. Further, the evidence-based guidelines for the treatment of acute asthma exacerbation in children do not discuss a humidifier as a treatment strategy for asthma. As a result, there is a lack of evidence-based data to support the medical necessity of a humidifier for the management of asthma. All told, the requested humidifier and purifier is not supported as medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for AndroGel 1.62% for treatment of the enrollees hypogonadism. Findings:  The physician reviewer found that proper treatment of hypogonadism is based on the improvement of symptoms related to erectile dysfunction, sexual dysfunction and related depressive symptoms, while maintaining normal testosterone levels. Other goals of therapy include prevention of osteoporosis, possible normalization of growth hormone and maintenance of virilization. The treatment has to be balanced against possible side effects. In younger men, the goal is to improve symptoms and maintain a testosterone level in the mid normal range. In older men, defined over 60 years of age in most studies, the recommendation is to keep levels in low normal range. In this patients case, the records support the requested medication dosage in order to optimize therapy and improve his depressive symptoms further. Therefore, AndroGel 1.62%, two pumps per shoulder daily is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medication dosage 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 endocrinology, diabetes and metabolism 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 spinal muscular atrophy testing for evaluation of the enrollees pregnancy with a family history of Down syndrome.  Findings: The physician reviewer found that the review of the submitted documentation and relevant literature fails to demonstrate the medical necessity of the spinal muscular atrophy testing performed. Although spinal muscular atrophy may be as frequent as 1 in 40 in the population, the American College of Obstetricians and Gynecologists (ACOG) do not recommend screening at this time. According to the ACOG Committee Opinion for spinal muscular atrophy, Before panethnic prenatal screening for [spinal muscular atrophy] SMA can be recommended there should be a variety of issues addressed which include, but may not be limited to, critical assessment of pilot screening programs, cost effectiveness analysis, development of appropriate educational materials for both patients and primary obstetriciangynecologists, and the development of laboratory assay standards and result reporting. In this case, given that the patient has no known risk factors for spinal muscular atrophy, the testing at issue was not medically necessary for evaluation of the patients medical condition.Final Result: The reviewer determined that the testing at issue was not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in obstetrics and gynecology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The parents of a thirteen year-old male with severe Crohns disease are requesting initiation of growth hormone therapy with Nutropin.  Reviewers Findings:The reviewing physician found that a six-month trial of growth hormone is medically appropriate to learn whether the complete cessation in growth can be overcome in this case.  The reviewing physician found that the Health Plan denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

A 53-year-old male enrollee has requested a continued follow-up appointment with an orthopedic surgeon for treatment of his lower back pain. Findings:  The physician reviewer found the submitted documentation and relevant literature demonstrates the medical necessity of the requested services. Based upon the documentation submitted, a further follow-up assessment with an orthopedic surgeon is clinically indicated. The patient has documented chronic lumbosacral pain with anatomical changes documented on MRI at multiple levels including disc protrusions and neural foraminal stenosis. According to the medical records, the request for a follow-up appointment with an orthopedic surgeon meets the standard of care for chronic lumbosacral condition as documented in the medical literature. Given the reasons provided, the requested services are medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested Otezla for treatment of her medical condition.  Findings: The physician reviewer found that review of the submitted documentation and relevant literature demonstrates the medical necessity of the requested medication. The patient is requesting coverage for Otezla (apremilast) for treatment of psoriasis. The Health Plan indicates that for treatment of psoriasis with Otezla the patient must have a psoriasis area severity index (PASI) score more than 10, a failure or intolerance/contraindication to methotrexate, etanercept (Enbrel) and adalimumab (Humira). In this case, the patient has displayed intolerance/contraindication to the above medications. Therefore, in this case, the patients request for Otezla is medically necessary. 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 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

The patient is a 36-year-old male with hyperlipidemia who underwent an electron beam tomography (EBT) scan for evaluation of and screening for possible coronary disease. The patient has requested reimbursement for the procedure at issue. The Health Plan has denied the request on the basis that EBT scanning of the heart is not medically necessary in the screening or management of coronary artery disease. EBT for cardiac disease is not the standard of care and has not been generally accepted in the medical community as standard diagnostic testing. Review of the medical literature indicates that EBT is not a medically appropriate replacement for other conventional screening tests within the standard of care such as treadmill stress testing. Thus, there is no evidence that EBT was medically indicated for evaluation of this patient. Therefore, I have determined that the procedure at issue was not medically necessary for evaluation of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 47-year-old female who was admitted to a skilled nursing facility (SNF) following an auto versus pedestrian accident, which occurred on 11/24/04. She was admitted to skilled care on 12/6/04 and discharged on 12/17/04. The patient reached contact guard assist (CGA) with physical therapy on 12/14/04. At that time, she was also CGA with toileting and LB bathing. She continues to receive physical therapy at home. There is no evidence that her home environment was assessed as safe and accessible. The patient has requested authorization for additional SNF services. The Health Plan has denied the request indicating the submitted documentation does not demonstrate additional SNF services are medically necessary. Inpatient rehabilitation is provided to patients who have care needs that cannot be met in the home. The submitted evidence indicates the patient was sent home in a dependent state. There is no evidence that at the time of discharge appropriate services were in place to meet the patients care needs. The patient had not met her maximum rehabilitation potential at the time of discharge and she could have benefited from continued rehabilitation services. Based upon the documentation provided, it is unclear what services the patient requires at this time. Therefore, I have determined the Health Plans denial should be upheld at this time. However, the Health Plan should provide a full home health care evaluation to determine the type of care the patient requires.
Appeal type: Medical Necessity
Decision: Upheld

A 48-year-old male enrollee has requested Magnetic Resonance Imaging (MRI) of the lumbar spine for an evaluation of his peripheral neuropathy. Findings:  The physician reviewer found that the patient has a history of chronic low back pain with radiating pains. A prior MRI done for similar symptoms showed no central or lateral foraminal stenosis. There is no clinical evidence of the development of radiculopathy or myelopathy by available reports. Additionally, there is no evidence that physical therapy is contraindicated in the setting of lumbar impingement or stenosis. Furthermore, an MRI is not generally indicated for the evaluation of peripheral neuropathy. Thus, an MRI of the lumbar spine should not be approved at this time. It would be appropriate to try a course of physical therapy, and if there is still no improvement, to then pursue a lumbar MRI. However, ultimately, the choice of diagnostic testing should be guided by expectation that the results will be of value in treatment planning.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for physical therapy with a Certified Functional Manual Therapist. Ehlers-Danlos syndromes are characterized by joint hypermobility, chronic severe pains, and fatigue. In addition to pain related to mechanical factors at the affected joints, a generalized hyperalgesia has been described that may be due to a sensitized central nervous system, implying underlying pain mechanisms similar to fibromyalgia. Rehabilitation aims to reduce disability and improve quality of life. The evidence related to the effectiveness of specific treatments for reducing disability in this patient population is limited. Therapy interventions such as manual therapy, taping, hydrotherapy, and relaxation training are frequently employed. However, there is a lack of high-grade evidence demonstrating the clinical benefits in the setting of the heritable hypermobility syndromes. Based on current data, specialized clinical training and additional certification in manual therapy over the manual therapy utilized by licensed physical therapists has not yielded superior health outcomes. In the present case, the patient reportedly developed severe back pain following a treatment aimed at the sacroiliac joint in July 2020. The evidence-based literature does not support that the proposed intervention by a therapist certified in manual therapy will effectuate a favorable impact on the patients clinical course or outcomes beyond standard physical therapy. Therefore, the requested physical therapy with a Certified Functional Manual Therapist is not medically necessary for treatment of 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 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: Experimental/Investigational
Decision: Overturned

A 57-year-old female enrollee has requested hyperbaric oxygen treatment for the treatment of her soft tissue radiation necrosis of the brain. Findings:  Two physician reviewers found that although there is a theoretical risk of worsening a tumor with HBO and/or inducing seizures, there are numerous case studies and reports to show adjunctive benefit in reducing complications from late central nervous system (CNS) effects of radiation. Some conflicting reports indicate there may be no benefit. However, there is sufficient evidence to suggest this patient may benefit from HBO considering that her providers have weighed other first-line options.
Appeal type: Medical Necessity
Decision: Upheld

A 58-year-old female enrollee has requested for radiofrequency lesioning for treatment of her history of back pain. Findings:  The physician reviewer found that there is a lack of documentation of clinical findings or imaging supporting an appropriate diagnosis for radiofrequency lesioning.  Additionally, the medical records do not demonstrate that the patient has tried and failed standard therapy, including three months of nonsteroidal medication and physical therapy.  Gofeld and colleagues performed a 10-year prospective clinical audit of lumbar radiofrequency denervation.  They concluded in the study that proper patient selection and anatomically correct radiofrequency denervation of the lumbar zygapophyseal joints provide long-term pain relief in a routine clinical setting.  Geurts and colleagues published a systematic review to assess the efficacy of radiofrequency procedures for the treatment of spinal pain.  The authors concluded that there is moderate evidence that radiofrequency lumbar facet denervation is more effective for chronic low back pain than placebo as long as the patients are appropriately diagnosed for lumbar facet pathology. The current medical evidence does not support the requested services in this clinical setting.  All told, the requested radiofrequency lesioning is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for 40 hours per week of applied behavioral analysis (ABA) therapy. Findings:  The physician reviewer found that a study evaluated the relationship between ABA treatment intensity and treatment outcomes for individuals with autism spectrum disorder. The authors reported a strong relationship between treatment intensity and mastery of learning objectives, where higher treatment intensity predicted greater progress was demonstrated. In this case, the patient appears to have made progress in many areas, but she continues to demonstrate impairment in several areas including poor eye contact, poor attention to stimulus and sensory defensiveness, outburst behaviors consisting of high pitched screams and aggression in the context of global developmental delays. These persistent struggles are making it increasingly difficult for her to be successful in more generalized environments. The Health Plan has authorized 24 hours per week of ABA therapy, which is on the low end of what is typically recommended for optimal response. Several studies have recommended 25 or more hours of weekly ABA to ensure optimal outcomes. The Behavior Analyst Certification Board states that typical comprehensive ABA programs range from 30-40 hours of treatment per week. Given the sufficient support in the peer-reviewed literature, 40 hours per week of ABA is medically necessary for treatment of the patients medical condition. 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 physician reviewer is board certified in pediatrics with sub-specialty certification in developmental-behavioral pediatrics 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.