Persius/imr-appeals huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for initial treatment and serial treatments, staged at the onset of epithelialization, using direct excision and fractionated carbon dioxide (CO2) laser to the bilateral face, scalp, chest, abdomen, left shoulder, and groin with topical application of 5-fluorouracil (5FU). Intralesional injection with triamcinolone acetonide (TAC) represents the gold standard in the treatment of keloids, with the fastest response. Fractionated CO2 has been demonstrated to be as efficient, and possibly more effective, than TAC for some patients. Given the severe symptoms associated with this patients disease including infection and purulent drainage, he would most likely benefit from TAC combined with fractionated CO2. However, the medical literature does not support the long-term safety and efficacy of 5FU for the treatment of keloids. Based on these findings, initial treatment and serial treatments, staged at the onset of epithelialization, using direct excision and fractionated CO2 laser to the bilateral face, scalp, chest, abdomen, left shoulder, and groin are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy, while the topical application of 5FU is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings:  Two of the three physician reviewers found the initial treatment and serial treatments, staged at the onset of epithelialization, using direct excision and fractionated CO2 laser are likely to be more beneficial for treatment of the patients condition than any available standard therapy, while the topical application of 5FU is not likely to be more beneficial for treatment of the patients condition than any available standard therapy.Final Result: The reviewers determined that a portion of 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 partially overturned. Credentials/Qualifications: Physician reviewers 1, 2, and 3 are board certified in dermatology 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested the prostatic urethral lift procedure (Urolift) for treatment of his medical condition. Findings: Two reviewers found that the review of the relevant peer-reviewed literature reveals a lack of support for the requested procedure in this patients case. While Urolift has shown initial safety and efficacy in the treatment of benign prostatic hyperplasia (BPH) symptoms, long term efficacy data is lacking to compare  the procedure to currently available ablative procedures such as laser photo selective vaporization of the prostate (PVP). Further research may reveal equivalence but study-controlled results are still pending. In the absence of long term data documenting the superior efficacy of the Urolift procedure, the requested procedure is not likely to be more beneficial for treatment of the patients BPH than standard treatment modalities.  Final Result: Two reviewers determined that the requested procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications:  All three reviewers are board certified in urology 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: Overturned

Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting authorization and coverage for high frequency chest wall oscillation air-pulse generator HCPCS Code E0483.The enrollee has a history of bronchiectasis secondary to tuberculosis.  Findings:Her bronchiectasis was diagnosed by a computerized tomography scan (CT) scan.  Bronchoscopy showed pseudomonas in the washings but was negative for acid-fast bacilli.  She was treated with ciprofloxacin for the pseudomonas.  A high frequency chest wall oscillation device along with nebulized therapy was prescribed.  Notes indicate her sputum had decreased with Cipro on the same visit.  She was seen again and her lung exam was clear. She was placed on Zithromax three times a week.  A pulmonary function test showed restrictive lung disease.  The pulmonologist indicates conventional means of chest therapy would not be effective as the enrollee does not have a caregiver to provide manual chest physiotherapy.  The enrollees  assessment score shows she breathes easier and sleeps better when using high frequency chest wall oscillation air-pulse generator. Review of the record indicates the enrollee has had multiple episodes of exacerbations of bronchiectasis, which required treatment with antibiotics.  On exam, she had vesicular breath sounds with bilateral rales and rhonchi.  Based on the enrollees history and pulmonary function tests that are suboptimal, high frequency chest wall oscillation air-pulse generator is appropriate to assist with her mucociliary clearance.  According to the medical literature, high frequency airway clearance assist devices provide an improvement both in pulmonary function and quality of life related parameters in enrollees with chronic hypersecretive disease. Final Result: The reviewer determined the requested service is medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in pulmonary 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for Nutropin AQ Nuspin human growth hormone.Findings:  The physician reviewer found that the submitted documents support that the requested medication is medically necessary. In 1985, growth hormone deficiency became the first indication for recombinant human growth hormone approved by the U.S. Food and Drug Administration (FDA), which it described as the treatment of pediatric patients who have growth failure due to inadequate secretion of endogenous growth hormone.  In this case, the patient has growth hormone deficiency on lab testing, and according to the growth trends showing growth failure. His bone age is severely delayed, which is also seen in growth hormone deficiency. His predicted adult height is below the target height range for his family. The patients growth chart reflects that the patient is experiencing growth failure over multiple years (Growth Hormone Research Society). The patient has demonstrated growth failure, height staying down the percentiles, low IGF-1 levels and a predicted adult height that is less than mid-parental height even if his bone age is severely delayed bone age. The patients presentation is consistent with growth hormone deficiency with a severe delay in bone age. Under these circumstances, the requested Nutropin AQ Nuspin human growth hormone is medically necessary for the patients medical condition.Final Result: The reviewer determined that the requested medication is medically necessary for the patient's medical condition. Therefore, the Health Plans denial should be overturned.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.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 56-year-old female with neck pain and temporomandibular joint (TMJ) dysfunction and jaw clicking, as well as low back pain. The patient received 12 physical therapy visits with an emphasis on low back pain and hip pain. The patient is able to open her mouth 40mm but continues to have pain. The Health Plan has denied the patients request for continued physical therapy on the basis that the requested therapy is not medically necessary.The 12 physical therapy visits received by the patient were for treatment of multiple problems with a focus on the patients low back pain and hip pain. The submitted information demonstrates the patient continues to have TMJ pain despite being able to open her mouth 40mm. Though it appears the patients back and hip pain has improved, she requires additional physical therapy that emphasizes the TMJ and neck area. Future therapy should emphasize an active approach and a home program.Based upon the information set forth above, I have determined that the requested therapy is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. The patient should receive an additional 12 physical therapy visits followed by reevaluation to determine if additional physical therapy is indicated.
Appeal type: Experimental/Investigational
Decision: Upheld

A 64-year-old male enrollee requested authorization and coverage of laparoscopic adjustable gastric banding (lap-band) surgery  for the treatment of morbid obesity.  The health plan denied the enrollees request indicating that the requested treatment is experimental.Three physician reviewers performed an experimental/investigational Independent Medical Review.  Each of the three physician reviewers concluded that laparoscopic adjustable gastric banding (lap-band) surgery  is not likely to be more beneficial for treatment of the enrollees morbid obesity than any available standard therapy.  Because all three physician reviewers concluded that the requested treatment is not likely to be more beneficial for treatment of the enrollees medical condition than any available standard therapy, the review organization upheld the health plans denial.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 15-year-old female enrollee has requested an intensive outpatient eating disorder program for the treatment of the enrollees eating disorder. Findings:  The physician reviewer found that the medical documentation indicates a period of increased anxiety and weight loss with a need for structure and supervision and therapeutic support to avoid further relapse while in IOP during the time frame in question. Thus, IOP during the time frame in question was clinically warranted and medical necessary for the patients medical condition and was consistent with treatment guidelines and standards of practice in this setting.
Appeal type: Medical Necessity
Decision: Upheld

A 63-year-old female enrollee has requested a power operated vehicle (POV) scooter for treatment of her sciatica and degenerative arthritis.  Findings:  The physician reviewer found that based on review of the available records, the patient is independent in mobility within her home and is independent with all MRADLs including home management. The Centers for Medicare and Medicaid Services (CMS) state that a power mobility device such as a power wheelchair or scooter is medically indicated for patients who have a mobility related deficit that impairs their ability to safely perform MRADLs within the home. In addition, the condition is not able to be ameliorated by a walker, cane or manual wheelchair. This patients records indicate that she has a personal mobility deficit, but is independent in all MRADLs within the home with a wheeled walker. Thus, applying the CMS guidelines, the requested power operated scooter has not been shown to be medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested breast tomosynthesis for evaluation of the enrollees medical condition.  Findings: Two physician reviewers found that the medical evidence supports the services at issue in this clinical setting.  Breast tomosynthesis provides advantages to radiologists interpreting mammograms.  This tomographic method often allows the reader to separate dense glandular elements from underlying mass/architectural distortion, resulting in a decrease in callbacks and increase in diagnostic accuracy and detection of small cancers compared to two-dimensional imaging alone.  Thus, the addition of breast tomosynthesis to the usual two-dimensional protocol was likely of greater benefit to the patient than had her examination been done with two-dimensional imaging alone.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 physician reviewers 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: Upheld

A 39-year-old female enrollee has requested inpatient psychiatric care services for treatment of her major depressive disorder, panic disorder, eating disorder not otherwise specified (NOS) and alcohol dependence.  Findings:  The physician reviewer found that the submitted medical records do not demonstrate that the patient met the severity of symptoms which would require her to be in a 24-hour supervised inpatient hospital setting as of the said date.  This patient did not have any suicidal or homicidal thoughts. She did not have any difficulty with her thought process which would require a 24-hour medical supervision. The patients substance abuse did not show acute withdrawal or previous severe withdrawal from alcohol or benzodiazepines. The patient was calm and cooperative with coherent and logical thoughts. In light of these findings, the patient did not meet American Psychiatric Association criteria for treatment in a 24-hour supervised inpatient psychiatric unit during the period at issue. Step-down to a partial hospitalization program (PHP) was medically necessary and appropriate for this patient as of the date in question.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Synvisc One injections. The current medical evidence supports the requested services in this patients case. Per the records, he has benefited from prior Synvisc One injections. There is good evidence that intra-articular hyaluronic acid injections reduce pain and increase function in knee osteoarthritis, and the benefits are long-lasting as compared with intra-articular corticosteroids. Researchers performed a systematic review of overlapping meta-analyses comparing viscosupplementation with other nonoperative treatment modalities for knee osteoarthritis. The authors noted that the current highest level of evidence suggests that intra-articular hyaluronic acid is a viable option for knee osteoarthritis. Per the authors, its use results in improvement in knee pain and function that can persist for up to 26 weeks. The authors reported that viscosupplementation has a good safety profile, and its use should be considered in patients with knee osteoarthritis. Therefore, the requested Synvisc One injections 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: Experimental/Investigational
Decision: Upheld

A 46-year-old male enrollee has requested Herceptin biochemotherapy and immunoassay CA19-9 testing for the treatment and an evaluation of his metastatic gastroesophageal cancer.  Findings:  Two physician reviewers found that although the patient is said to be responding, based on notes about the PET and despite what appears to be a rising CA19-9, the rationale for this regimen is extremely weak, and approval is not recommended based on the available data at the time the regimen was begun. The recommendation for a multi-drug regimen with two antibodies and 2 drugs was based on extrapolations rather than data, and based on claims of benefits from single-arm trials compared with historical controls. According to the provider, the patient was responding to that regimen, although this was not apparent from the submitted documentation. The provider provides data from molecular analysis of the patients tumor cells directed at expression of the pathways that represent targets for the drugs under consideration. However, this rationale is unfounded by any correlative data from solid clinical trials. Further, there are serious safety reservations for a regimen of three cardiotoxic drugs given together. There is no published information about addition of Sunitinib, a known cardiotoxic agent.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a dopamine transporter single photon emission computed tomography (DaT-SPECT). The diagnosis of Parkinsons disease is determined by clinical means. Several other diseases can have Parkinsonian features, making them difficult to distinguish from primary Parkinsons disease. DaT-SPECT uses imaging to determine presence, location, and the amount of dopamine transporters in dopaminergic cells. This modality is effective in distinguishing patients with Parkinsonian syndromes from those with Parkinsons disease. Given this support, the requested DaT-SPECT imaging scan is likely to be more beneficial for evaluation of the patients medical condition than any available medical therapy.Findings:  Three physician reviewers found the requested DaT-SPECT imaging scan is likely to be more beneficial for evaluation of the patients medical condition than any available medical therapy.Final Result: The reviewers determined that the requested DaT-SPECT imaging scan is likely to be more beneficial for evaluation of the patients medical condition than any available medical therapy.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in neurology 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: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested endovenous ablation of the left leg for treatment of her medical condition. Findings: The physician reviewer found that the documentation provided for review does not support the medical necessity of the requested procedure. Since the ablation of the patients bilateral GSV (great saphenous vein), her symptoms have resolved and there is no medical record documentation of any symptoms on the left side. Further, there is no documentation of the presence of an ulcer that is resistant to compression treatment or that the patient has been using medical grade compression stockings on a regular basis. For these reasons, the requested endovenous ablation of the left leg is not medically necessary for treatment of this patients varicose veins.  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 physician reviewer is board certified in surgery with sub-specialty certification in vascular 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 reimbursement for continuous positive airway pressure (CPAP) supplies. The submitted documentation supports the medical necessity of the requested equipment. This patient was diagnosed with obstructive sleep apnea and was prescribed CPAP therapy. It is well-established within current practice guidelines that CPAP supplies should be replenished on a periodic basis for patients who are compliant with treatment. This is in part to maximize patient therapy with the devices. In this case, the replacement supplies that were furnished to the patient were medically indicated. Therefore, CPAP supplies were medically necessary for the treatment of this patient. Final Result: The reviewer determined that the equipment at issue was 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 with sub-specialty certification in sleep medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 34-year-old female enrollee requested authorization and coverage of gastric bypass surgery for the treatment of morbid obesity.  The Health Plan denied the enrollees request indicating that the requested treatment 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 surgery is medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 16-year-old female enrollee requested mental health residential treatment center (RTC) services for medical treatment of the enrollees behavioral health issues. Findings:  The physician reviewer found that applying the American Society for Addiction Medicine (ASAM) criteria, the mental health RTC services provided to this patient were medically necessary for treatment of her medical condition. Based on review of the available records, the patient did not have sufficient coping techniques to avoid a possible relapse if she had been discharged to a lower level of care. The patient had a difficult time on her pass home which also supports the need for continued treatment. In addition, she was opposed to a step-down treatment until only a few days before her discharge. Therefore, the RTC services were medically necessary to help the patient develop appropriate coping strategies and to develop a realistic discharge plan that would prevent a relapse.