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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the prostatic lift implant.Findings:  Two physician reviewers found that the prostatic UroLift system is a minimally invasive approach to treating benign prostatic hyperplasia (BPH) that lifts or holds the enlarged prostate tissue out of the way so that it no longer blocks the urethra. Recent clinical trials including prospective sham controlled randomized studies have shown that the UroLift system treatment is safe and effective in relieving lower urinary tract symptoms due to BPH without significantly compromising sexual function. However, other treatment options including medications and transurethral surgery were offered to this patient. It is unclear if the patient was a good candidate for UroLift procedure from the records provided for review. The patient has urinary retention from unknown etiology but there is no evaluation to determine etiology as from bladder outlet obstruction or detrusor dysfunction. The current medical literature does not support use of UroLift in patients with urinary retention. Final Result: Two reviewers determined that the service at issue was 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 physician reviewers are board certified in urology and are actively racticing. 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

A 39-year-old female enrollee requested a panniculectomy for medical treatment of her excess skin status post bariatric surgery and weight loss.   Findings:  The physician reviewer found that as noted by the American Society of Plastic Surgeons (ASPS), when surgery to remove extensive skin redundancy and fat folds is performed solely to enhance a patients appearance in the absence of any signs or symptoms of functional abnormalities, the procedure should be considered cosmetic in nature and not a compensable procedure. In this case, the medical documentation supports that the functional deficit is related to the upper and lower abdominal pannus. Manahan and Shermak recommend panniculectomy in this clinical setting. Thus, based on the entirety of the medical record, the patient has a well-defined functional deficit related to excess abdominal soft tissue from previous significant weight loss. Resection of the excess soft tissue is medically necessary to address this specific functional deficit.
Appeal type: Medical Necessity
Decision: Upheld

An 18-year-old male enrollee has requested partial hospitalization program services for treatment his generalized anxiety disorder, attention deficit hyperactivity disorder, and learning disorder (dysgraphia and dyslexia).  Findings:  The physician reviewer found that the progress notes provided for review indicate the patient was able to maintain the gains that he achieved while an inpatient at thte specified location. The providers notes dated on the specified date suggest that this patient has achieved maximum benefit from his PHP treatment. While in the PHP, he did not revert to any aggressive behaviors and was no longer a threat to himself or others. Although the patient still required some structure and prodding to attend PHP, he was generally cooperative with therapy, and his home environment is supportive. All told, treatment at the PHP level is not supported as medically necessary for treatment of this patients medical condition from the specified date and forward.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for pregabalin 75 mg, two tablets a day.The use of gabapentin, another related gamma aminobutyric acid (GABA) analog, is recommended by American College of Chest Physicians for the management of unexplained cough, not mediated by asthma, eosinophilic/allergic processes, upper airway cough syndrome, or gastroesophageal reflux. Additionally, according to Vertigan and colleagues, pregabalin was effective in treating chronic refractory cough in a randomized trial in which 40 adults were assigned to take pregabalin with speech pathology treatment (SPT) or placebo with SPT. Moreover, the use of gamma aminobutyric acid analogs (including pregabalin) for the treatment of chronic refractory cough, particularly when providers suspect a central mechanism, is standard practice in pulmonary medicine and often highly effective in curbing or eliminating debilitating cough syndromes. In this case, the patient has a chronic cough that has not been successfully treated with other medication. Additionally, testing has eliminated other causes for the cough. The records show that the patient has shown improvement while taking pregabalin. Thus, the requested pregabalin 75 mg, two tablets a day, is medically necessary for the treatment of the patients medical condition.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 internal medicine with sub-specialty certification in pulmonary disease 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 male enrollee requested Lyrica 75 mg three times per day for treatment of his neuropathic pain as a result of cervical arthritis and impingement.  Findings:  The physician reviewer found the medical records provided for review document that this patient has physical exam findings and imaging studies consistent with radiculopathy and neuropathic pain. Additionally, there is further documentation that the patient failed other anticonvulsant medications in the same class. Given that this patient does seem to be exhibiting neuropathic or radicular pain and has failed trials of similar medications, Lyrica is medically necessary at the requested dosage of 75 mg three times per day.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary:   An enrollee has requested computer assisted navigation for total knee replacement (CPT code 20985) for treatment of her right knee osteoarthritis.  Three physician reviewers found that according to the referenced literature, computer assisted navigation with total knee replacement is beneficial in improving restoration of the joint line, decreasing perioperative blood loss, and improved functional outcome in those undergoing total knee arthroplasty. However, there is a lack of long term studies indicating longevity of functional outcome and prosthesis, and therefore, further studies are needed. As more studies are needed regarding the long term efficacy, the longevity of the prosthesis and functionality, computer assisted navigation was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: Three reviewers determined the services at issue were 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 orthopedic surgery 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

The patient is a 58-year-old female with breast cancer and possibly ovarian cancer. She is known to have BRCA-2 mutation and has requested consultation with a gynecologic oncologist. The Health Plan believes the patient can be appropriately evaluated by a general gynecologist and that a referral to a gynecologic oncologist is not medically necessary.General gynecologists have little, if any, cancer-genetic training. The patient should consult with a gynecologic oncologist to understand all of the available treatment options. Any ovarian cancer staging with retroperitoneal resection should be performed by a gynecologic oncologist  not a general gynecologist. Because this patient has a known BRCA-2 mutation and is a known risk for tubal cancer she requires evaluation by a gynecologic oncologist, which is the specialty trained to address the patients cancer-genetic issues and would be the specialty to perform necessary procedures. For these reasons, I have determined the requested referral is medically necessary for evaluation of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of a patient has requested authorization and coverage for 24-hour a day shift nursing care. The Health Plan has denied this request indicating that the requested services are not medically necessary for treatment of the patient, who has a history of anoxic encephalopathy. The submitted documentation supports the medical necessity of a portion of the requested services. Based upon the records and medical literature, 60 hours per week is recommended in this clinical setting, to be utilized flexibly to allow the parental caregivers to work. The patient has skilled medical needs that include administration of oxygen via tracheostomy collar, tracheostomy suctioning, tracheostomy changes, gastrostomy tube feeding, and medication administration via gastrostomy tube. When the parents are not available due to working outside of the home, a skilled care provider is required to meet the care needs of this patient. The medical evidence supports a portion of the requested services. All told, 60 hours per week of shift nursing care is medically necessary for the treatment of this patient. Final Result: The reviewer determined that a portion of the requested services are 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 pediatrics with sub-specialty certification in pediatric critical care 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: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for a Bioness L300 Go Plus Brace System for the calf and thigh with electrodes and Bioness L300 Go Plus replacement electrodes. Findings:  Three physician reviewers found that there is limited high-quality peer-reviewed literature available on functional electrical stimulator (FES) devices for gait with incomplete spinal cord injury, including FES for treatment of gait instability with foot drop. Existing studies discuss promising initial results. However, these studies have been small and any findings require confirmation through further research. There is insufficient published research at this time to support this treatment to be established as more effective than standard therapy. All told, the Bioness L300 Go Plus Brace System for the calf and thigh with electrodes and Bioness L300 Go Plus replacement electrodes were not likely to be more beneficial for treatment of the patients medical condition than any available medical therapy.For these reasons, the Bioness L300 Go Plus Brace System for the calf and thigh with electrodes and Bioness L300 Go Plus replacement electrodes were not likely to be more beneficial for treatment of the patients medical condition than any available medical therapy.Final Result: The reviewers determined that the Bioness L300 Go Plus Brace System for the calf and thigh with electrodes and Bioness L300 Go Plus replacement electrodes were not likely to be more beneficial for treatment of the patients medical condition than any available medical therapy.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in physical medicine and rehabilitation 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: Overturned

Nature of Statutory Criteria/Case Summary:An enrollee has requested reimbursement for Oncotype DX testing for evaluation of the enrollees breast cancer. Findings:  The physician reviewer found that Three physician reviewers found Oncotype DX is an assay used to assess the risk of breast cancer recurrence. The National Comprehensive Cancer Network assay recurrence score can be considered in select patients with one to three involved nodes on the same side as the cancer to guide the addition of combination chemotherapy to standard hormone therapy. A retrospective analysis of a prospective randomized trial suggests that the test is predictive in this group. The medical evidence supports the services at issue in this clinical setting. Therefore, Oncotype DX testing was likely to have been of greater benefit than other methods of evaluating this patient. Final Result: The 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: Physician reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in medical oncology 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 56-year-old female enrollee has requested for weekly individual psychotherapy appointments for three months for treatment of her major recurrent depression. Findings:  The physician reviewer found that the intensive outpatient treatment (3-4 hours per session/3 sessions per week) is actually a more intense level of service than the weekly sessions with an individual therapist. The submitted evidence does not demonstrate that the patient is likely to derive greater benefit from individual psychotherapy than from the treatment.
Appeal type: Medical Necessity
Decision: Upheld

The grandparent of a 3-year-old male enrollee requested authorization and coverage of further laboratory testing to rule out neuroimmune dysfunction syndrome. The enrollee has a diagnosis of autism spectrum disorder/pervasive developmental delay.  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 upheld the health plans denial on the basis that the requested services are not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for home health nursing assistance. Dystrophic epidermolysis bullosa is a subtype of epidermolysis bullosa that results in extremely fragile mucocutaneous tissues with complications including intractable ulcers, extensive scarring, recurrent corneal erosions, and malnutrition. The standard of care is symptomatic treatment with meticulous wound care and use of protective dressings to prevent severe wound infections. This patient requires daily skin cleansing and dressing changes, with judicious use of antibiotics for infected wounds or those that fail to heal. Treatment consists of a multi-step process involving cleansing the skin, lancing blisters, treating infected and poorly healing lesions with topical antibiotic, and applying multilayered wound dressings. Home health nursing can assist in managing the patients pain and anxiety related to wound care. In order to provide this patient with appropriate care, the requested home health nursing assistance is 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 pediatrics with subspecialty certification in pediatric critical care 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 56-year-old female enrollee has requested for breast MRI with computer aided detection (CAD) for her breast cancer screening.    Findings:  The physician reviewer found that this use of the MRI is not purely for screening, but is to evaluate suspicious calcifications which apparently are not associated with a clearly palpable lesion in patients with very dense breast tissue. This represents a reasonable use of MRI to increase the sensitivity of detecting a cancer in that area. The above cited article by S. Harms outlines the difficulty in evaluating dense breast tissue and the utility of MRI in evaluating mammographic abnormalities in the setting of dense breast tissue.
Appeal type: Medical Necessity
Decision: Upheld

A 40-year-old female enrollee has requested BRCA1 and BRCA2 genetic testing for an evaluation of her risk of breast cancer. Findings:  The physician reviewer found that a study by McPherson and colleagues noted that florid epithelial hyperplasia is a benign finding that carries a slightly higher risk of breast cancer, estimated at 1-2 fold over normal. This risk is higher with the presence of atypia, but there is no evidence suggesting that this breast pathology shows a high prevalence of BRCA1 or BRCA2 mutation. Additionally, epithelial hyperplasia does not warrant consideration of chemoprevention. There are specific guidelines that direct genetic testing for BRCA1 and BRCA2. A single first degree relative with breast cancer does not suggest a BRCA mutation in the family, especially in an individual with non-Ashkenazi family history. The Health Plans finding that it is not medically necessary to test this patient is consistent with the guidelines published by the U.S. Preventive Services Task Force.
Appeal type: Medical Necessity
Decision: Upheld

A 58-year-old female enrollee has requested Supartz injections (right knee) for treatment of her osteoarthritis. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  The current medical evidence does not support the requested services in this clinical setting.  There have been double-blinded studies which do not document clinical effect from hyaluronan injection.  Additionally, there is a documented incidence of aseptic inflammatory reactions due to allergic response and a risk of iatrogenic infection within the joint.  Rutjes and colleagues performed a meta-analysis to evaluate the risks and benefits of viscosupplementation for adults with symptomatic knee osteoarthritis.  The authors noted that viscosupplementation is associated with a small and clinically irrelevant benefit and that there is an increased risk of serious adverse effects.  All told, the requested Supartz injections are not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Synvisc-One injection to the left knee. The Health Plan has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees medical condition.Findings: Nationally recognized evidence based medical guidelines state that hyaluronic acid injections in the knee are recommended as a possible option for patients with severe osteoarthritis who have not responded adequately to recommended conservative treatments for at least three months, including failure to adequately respond to aspiration and injection of intra-articular steroids. The medical literature supports hyaluronic acid injections to potentially delay total knee replacement for patients with pain that interferes with functional activities. If there is documented significant improvement in symptoms for six months or more, and symptoms recur, it may be reasonable to administer another series. There is no maximum amount of injections established by high quality scientific evidence. However, while medial and/or lateral compartment osteoarthritis is a recommended indication, there is insufficient evidence for other conditions including patellofemoral osteoarthritis, chondromalacia patella, patellofemoral syndrome (kneecap pain), or osteochondritis dissecans. Peer reviewed literature supports the use of hyaluronic acid injections for chronic moderate symptomatic osteoarthritis of the knee but states that application in sports related chondropathy has yet to be fully assessed. The ideal indication in the knee seems to be moderate femorotibial osteoarthritis without swelling.This patient presents with a history of left knee patellofemoral osteoarthritis. Clinical examination findings have been consistent imaging findings of patellofemoral degenerative joint disease. She reported improvement with prior Synvisc-One injection with functional improvement in work ability. However, as detailed above, evidence based medical guidelines and literature do not support the use of Synvisc-One injections for patellofemoral osteoarthritis, or for mild femorotibial osteoarthritis. Therefore, in this patients case, Synvisc-One injection in the left knee has not been established as medically necessary for the treatment of this 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 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: Overturned

A 57-year-old female enrollee requested a real-time heart monitor for medical evaluation of her atrial fibrillation. Findings:  Two physician reviewers found that given this patients complex congenital heart disease, history of recurrent atrial fibrillation, and limited medical therapy options because of bradycardia, the real-time cardiac monitoring was the most appropriate and likely the highest yield diagnostic test available. Thus, the real-time heart monitor was likely to have been more beneficial for evaluation of this patients medical condition than any available standard therapy.