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

The patient is a 65-year-old female with type 2 diabetes mellitus who is also morbidly obese according to her provider.  She had significant improvement after a short trial of Byetta with a weight loss of 13 pounds and a decrease in her hemoglobin A1c of 0.3%. The patients hemoglobin A1c rose by 1% after Byetta was discontinued.  The patients provider has requested authorization for continued treatment with Byetta. The Health Plan denied the request citing a lack of medical necessity.Two important goals in the treatment of type 2 diabetes are weight reduction and optimal blood glucose management. In this case, the patients initial response to Byetta was consistent with those goals as she lost 13 pounds and improved her hemoglobin A1c by 0.3%. During her brief trial of Byetta, her hemoglobin A1c was initially above the maximum ADA goal of 7.0% (7.1%) and with the medication it dropped to within the ADA goal range (6.8%). Without Byetta, the patients blood glucose control deteriorated and her hemoglobin A1c was again above the ADA goal at 7.8%.  Continued treatment with Byetta is medically appropriate and likely to improve the patients management of her type 2 diabetes.Based upon the information set forth above, I have determined the requested medication is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

A 46-year-old female enrollee has requested reimbursement for a wearable cardioverter defibrillator (LifeVest) provided for seven months for treatment of the enrollee, who has been diagnosed with severe non-ischemic dilated cardiomyopathy.   Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the device at issue.  Based on the records provided, the patient presented with a newly diagnosed non-ischemic cardiomyopathy, with an ejection fraction reported to be 25% to 34% on imaging studies.  At the time of diagnosis, there was potential for recovery of left ventricular function with appropriate treatment, and there was no indication for immediate placement of a defibrillator, such as sustained or inducible ventricular tachycardia or syncope due to sudden cardiac arrest.  Placement of a prophylactic defibrillator is not recommended until a period of time has elapsed (greater than 90 days) where continued severe left ventricular dysfunction is documented to persist in spite of appropriate treatment.   Placement of a prophylactic defibrillator before this time has not been demonstrated to improve outcome.  The current medical evidence does not support the use of the device at issue in this clinical setting.  All told, the wearable cardioverter defibrillator (LifeVest) was not medically indicated in this patients case.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the tissue graft, to repair a forehead scar for treatment of the enrollees scar tissue and depression of right upper forehead.Findings:  The physician reviewer found that the patient presented with evidence of significant forehead depression as a result of instrumentation from a previous hospitalization due to an automobile accident. Photographs and medical documentation support a significantly abnormal condition. There is no evidence of a functional deficit. However, the patients appearance is significantly abnormal and the surgery is an attempt to create a normal appearance. In addition, fat grafting would offer more than a minimal improvement in the appearance of the patient. Final Result: The reviewer determined that the services at issue were medically necessary and reconstructive in nature for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in plastic 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: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for air and associated ground ambulance services.Findings:  The physician reviewer found that in this clinical setting, the submitted documentation does not support the medical necessity of the services at issue. Air ambulance is considered medically necessary under certain circumstances. The medical literature identifies these circumstances to include when the point of pickup is inaccessible by land or there is a great distance or obstacle involved in land transport. Another circumstance would be when the time needed to transport the patient by land poses a threat to a patients survival or the proper equipment needed for the patient is not available on a land ambulance. Patient conditions to be considered include: unstable vital signs, spinal cord injury, severe chest or abdominal injury, severe burns, or amputations. In such cases, the service is covered to transport the patient to the closest inpatient facility capable of caring for the patient.  In this case, while the patient was approved to receive services at an out of state facility, transport to that facility could have been accommodated by commercial flight or private vehicle. The records indicate the patient had one glucose level tested at the beginning of her transport. Her vital signs were stable and the patient did not require supplemental oxygen. Additionally, the flight paramedics noted that no intravenous access was warranted. As such, the documentation submitted did not meet the recommended guidelines for air ambulance transportation. Final Result: The reviewer determined that the services at issue were not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in emergency 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: Upheld

The patient is a 55-year-old female with low back pain, chronic in nature. She is status post laminectomy. The patient is requesting authorization for ongoing physical therapy with the Back Strong device. The Health Plan has determined that the requested therapy is not medically necessary.The Back Strong device is not essential for continued rehabilitation of the patients back pain. There is no peer-reviewed literature demonstrating the superiority of this device when compared to traditional skilled physical therapy and back care strengthening stabilization exercises. Future physical rehabilitation programs should include a daily home exercise program so that the patient can maintain her back strength. Therefore, I have determined the requested therapy is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

A 45-year-old female enrollee has requested physical therapy for the treatment of her back pain. Findings:  The physician reviewer found that the patient was treated with exercises for adductor muscles, hamstrings, iliotibial band, midback stretches, isotonics for SLR abduction and bridging, and manual interventions for erector spinal or psoas. While the patient indicates that this therapy was for her right leg and plantar fascia, the physical therapy notes repeatedly indicate treatment to the low back and left hip and the procedures performed are consistent with this. In addition, while the patient did get additional treatment for plantar fasciitis, it is also clear that treatment for her back continued during this time frame as documented by the physical therapy notes in terms of the procedures performed (such as midback rotations and quadratus muscles exercises, etc.) Thus, the incident which initiated another prescription of therapy does reflect a flare-up of the back pain treated. Furthermore, review of the therapy notes again documents the same procedures of manual interventions to erector spinal, quadratus stretching to iliotibial band, hamstrings, SLR abduction, adduction, and similar modalities. Thus, the treatment regimen was not significantly different from the therapy she previously received. The goals were to achieve improved strength, which the patient received instruction in doing with the 12 previous sessions of PT. Walking, sitting, and standing tolerance were 0-10 minutes. Thus, there is no objective documentation of improvement and the patient could have continued strengthening using the home program she had received. Nor is there any evidence additional physical therapy is warranted at this point in time.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested the brand name medication Colcrys for treatment of her medical condition. Findings:  The physician reviewer found that when a generic drug product is approved by the U.S. Food and Drug Administration (FDA), it has met rigorous standards established by the FDA with respect to identity, strength, quality, purity and potency.  Generic drugs are required to have the same active ingredient, strength, dosage form and route of administration as the brand name product.  Through a review of bioequivalence data, the FDA ensures that the generic product performs the same as its respective brand name product.  This standard applies to all generic drugs, whether immediate or controlled release.  In this case, the documentation does not support that the patient has had any adverse reactions to the generic equivalent of colchicine.  The efficacy of the generic colchicine is considered equivalent to the brand name medication Colcrys.  Therefore, the requested brand name medication Colcrys is not medically indicated 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 internal medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested percutaneous tibial nerve stimulation (PTNS) for treatment of her medical condition. Findings:  Two physician reviewers found that PTNS was likely to be more effective for this patient than other available options. According to the American Urological Association (AUA) guidelines for the treatment of overactive bladder, PTNS is considered an acceptable third-line treatment option when first-line and second-line options have been tried and failed. In this case, both first and second-line treatments have failed, and treatment with PTNS was clinically indicated and appropriate. Therefore, the services at issue were likely to be more beneficial than standard medical therapy in this clinical setting.Final Result: The reviewers determined that the services at issue were likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: Reviewers 1, 2, and 3 are board certified in urology 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 22-year-old female enrollee has requested a bilateral breast reduction/mammoplasty for the treatment of her bilateral macromastia. Findings: The physician reviewer found that the medical records note that the patient has had an adequate trial of conservative therapy. Breast reduction surgery is effective in relieving the symptoms related to large breasts such as back pain, neck pain, shoulder bra strap grooving and skin breakdown, if they are present. In this case, the patients symptoms have been present for more than one year and are due to macromastia. To further delineate this group of patients, the Schnur scale was developed to relate the amount of breast tissue removed to preoperative body mass surface area as a means of differentiating cosmetic from reconstructive medically necessary breast reduction surgery. As the amount of tissue removed is increased, the procedure changes from a cosmetic procedure to a medically necessary reconstructive procedure. For this patient, the removal of 550 grams of tissue or more meets these criteria. The patients provider has planned to remove 500 grams, which does not meet these criteria. Therefore, the requested bilateral breast reduction/mammoplasty is not medically necessary for this patient.
Appeal type: Medical Necessity
Decision: Upheld

A 31-year-old female enrollee has requested duodenal switch revisional surgery for treatment of her obesity status post Roux-en-Y gastric bypass surgery.  Findings:  The physician reviewer found that there is no evidence of anatomical complication or overt failure of the prior procedure and no dietary or psychological evaluations were provided for review. The patient may require a revision for further weight loss at some juncture, however at this time the clinical necessity of the surgery is not supported with documentation of failure with aggressive dietary and behavioral efforts. It should be noted that even the duodenal switch procedure is not without risks and is merely one tool in an arsenal of weight loss options. This patient was noted to have late weight regain, which is even possible with the duodenal switch procedure. As such, there is no guarantee this patient will not regain weight with the requested procedure unless lifestyle changes including dietary and behavioral modifications are initiated and maintained.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for reoperation with reduction of the cerebellar tonsil and possible partial posterior fossa cranioplasty. The records provided for review document that this patient underwent Chiari decompression in December 2018, but her symptoms have continued to worsen. The patients postoperative imaging shows tonsillar decent of 25 mm. Following a thorough evaluation, the patients providers have recommended reoperation. Arnautovic and colleagues noted that a Chiari malformation type 1 is a hindbrain disorder associated with elongation of the cerebellar tonsils, which descend below the foramen magnum into the spinal canal. Clinical symptoms mainly develop from alterations in cerebrospinal fluid flow at the foramen magnum and the common subsequent development of syringomyelia. On review of the current medical literature, the authors noted that syringomyelia was resolved or improved in 78% of patients following surgical interventions including posterior fossa magnum decompression and tonsillar resection. This patients providers have planned a repeat operation to reduce her tonsils and possibly perform posterior fossa cranioplasty. The requested reoperation for this patients persistent symptoms after initial Chiari decompression is appropriate and consistent with the current medical literature. Therefore, the requested reoperation with reduction of the cerebellar tonsil and possible partial posterior fossa cranioplasty 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 neurological 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

The parent of a 13-year-old female enrollee has requested an additional fifty-two (52) speech therapy visits for the treatment of the enrollees post traumatic encephalopathy. Findings:  The physician reviewer found that the relevant scientific literature includes an article by Simms which places language disorders in a framework that offers a rational approach to the evaluation and treatment of patients with speech and language disorders. Speech and language therapy is well justified based on this patients diagnosis which is clearly established and well-documented in this case. This patients delays are attributable to an underlying medical insult to the brain. Patients who undergo such trauma have legitimate medical illnesses and require extensive treatment of the concomitant results of the underlying injury or insult. This patient has shown steady improvement with speech and language therapy and should continue to receive such services at the frequency and duration that has been requested. Her treatment plan is comprehensive, has shown positive results thus far, and is likely to continue to be beneficial.
Appeal type: Medical Necessity
Decision: Overturned

A 46-year-old female enrollee has requested a reconstructive surgery consultation following her double mastectomy. Findings:  The physician reviewer found that post-mastectomy breast reconstruction is medically necessary. This patient has undergone medically necessary mastectomies and has not yet had a reconstruction. The Womens Health and Cancer Rights Act (WHCRA) mandates insurance coverage for all stages of reconstruction. This patient has not had all stages of reconstruction. Required coverage includes all stages of reconstruction of the breast on which the mastectomy was performed, surgery and reconstruction of the other breast to produce a symmetrical appearance, prostheses and treatment of physical complications of the mastectomy, including lymphedema.
Appeal type: Medical Necessity
Decision: Upheld

A 66-year-old male enrollee has requested for home health care services for treatment of her spinal cord injury. Findings:  The physician reviewer found that The services provided to this patient could be performed by a layperson after proper training by a home health services agency. Often intermittent urinary catheterization is performed by patients, family members, or caregivers and skin, bowel and bladder care over the long term can be managed appropriately by non-technically trained individuals. The needs of this patient are long term in nature and the care he has been and currently is receiving appears custodial in nature, as not much recovery was to be expected. Therefore, the services at issue were not and are not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee requested reimbursement for hyaluronan injections. A review of the literature pertaining to viscosupplementation reveals mixed results. Studies have tried mixing hyaluronic acid with corticosteroids, platelet-rich plasma, and other agents to make it more effective. Viscosupplementation is recommended for patients with a history of lasting benefit from prior injections and in carefully selected cases where the options are limited. In this case, there is no documentation of prior viscosupplementation. She had palpitations and deterioration of her eyesight from corticosteroid injections. As such, her options were limited. The osteoarthritis in her knees was reportedly mild. Therefore, she was not a candidate for a total knee arthroplasty. Based upon the degree of chronic knee pain and limited options with an inability to take corticosteroid injections, the services at issue were medically necessary. Therefore, hyaluronan injections were medically necessary for the treatment of this patient. 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 orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a four-year-old male enrollee has requested an MRI of the brain with anesthesia for an evaluation of the enrollees autism and/or minor seizures. Findings:  The physician reviewer found that the patients primary doctor in her letter reports minor seizures five months after the neurologists evaluation. However, since there are no records nor any documented history confirming the presence of epilepsy or seizures, the MRI is not medically necessary. Although a MRI is sometimes obtained in children with autism, autistic patients have a high incidence of epilepsy (approximately 50%). In epileptic patients, a cerebral imaging study (preferably a MRI) is indicated. However, since the submitted medical records state there is no evidence of seizures or convulsions in this case, the proposed MRI is not indicated.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 41-year-old woman who is requesting coverage for treatment of toenail fungus with Lamisil tablets. The Health Plan has denied this request on the basis the requested medication is not medically necessary for treatment of the patients condition.Review of the submitted medical records does not include a history or provide any physical findings. Furthermore, there is no evidence of onychomycosis or discussion of functional impairment. Nor have laboratory results (i.e. microscopic exam or fungus culture) been provided. Therefore, there is insufficient evidence to support the request for Lamisil. Accordingly, I have determined that the requested medication is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.