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

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for Epidiolex 100 mg/mL, dosed at 150 mg twice a day.Scientists have explained that cannabidiol (CBD) is one of the cannabinoids with non-psychotropic action, extracted from Cannabis sativa. CBD is a terpenophenol, and it has received a great scientific interest thanks to its medical applications. This compound showed efficacy as anti-seizure, antipsychotic, neuroprotective, antidepressant and anxiolytic. The neuroprotective activity appears linked to its excellent anti-inflammatory and antioxidant properties. Researchers state that the results of scientific studies obtained so far on the use of CBD in clinical applications could represent hope for patients who are resistant to all conventional anti-epileptic drugs. Researchers have noted that almost a third of patients with epilepsy have a treatment-resistant form, which is associated with severe morbidity and increased mortality. The requested medication in this case, Epidiolex, is a pharmaceutical formulation of highly purified CBD in oral solution, 100 mg/ml, usually administered at 2-10 mg/kg/day. It has been demonstrated to be an effective long-term treatment option in Lennox Gastaut syndrome and Dravet syndrome, two forms of intractable generalized epilepsy syndromes in children, and is approved by the FDA for those conditions.In this case, the patient has had an EEG, with video EEG telemetry, and MRI of the brain, and she has a diagnosis of Lennox-Gastaut syndrome with refractory focal and generalized seizures. The patient has been on multiple previous anticonvulsants, including levetiracetam, lamotrigine and clonazepam, none of which resulted in adequate seizure control. The patient has achieved and maintained a positive clinical response with Epidiolex as evidenced by a decreased seizure frequency (less than 1 seizure per month, compared with one to two seizures per week before Epidiolex) and duration (seizures now last seven to ten minutes, are less intense, and now stop spontaneously, whereas previously the patient required rectal Diastat to abort a prolonged seizure). Under these circumstances, the requested medication, Epidiolex 100 mg/mL, dosed at 150 mg twice a day, is medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested medication is medically necessary to treat the patient's medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in neurology with special qualification in child neurology 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 47-year-old female enrollee requested authorization and coverage of enrollment in a protocol entitled Non-Myeloablative Allogenic Hematopoietic Stem Cell Transplantation Using Antithymocyte Globulin with either Melphalan and Cladribine or Total Lymphoid Irradiation. The Health Plan denied the request indicating that the requested therapy is considered experimental for the treatment of the enrollees metastatic breast cancer.Three physician reviewers performed a medical necessity Independent Medical Review. All three physician reviewers concluded that the requested therapy is not likely to be more beneficial for the treatment of the enrollee's medical condition than any available standard therapy. Because all three  physician reviewers concluded that the requested procedure is not likely to be more beneficial for the treatment of the enrollee's medical condition than any available standard therapy, the Health Plans denial has been upheld.
Appeal type: Medical Necessity
Decision: Upheld

A 60-year-old male enrollee has requested transurethral microwave therapy (TUMT) for treatment of his benign prostatic hyperplasia.   Findings:  The physician reviewer found that the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested therapy. The requested transurethral microwave therapy is not recommended for primary therapy for non-surgical candidates. Transurethral resection of the prostate (TURP) has been the gold-standard treatment for alleviating urinary symptoms and improving urinary flow in men with symptomatic BPH (Hoffman et al). Further, current peer-reviewed literature lacks adequate randomized controlled data to support the efficacy of TUMT for retention alone. In sum, there is a lack of medical literature that supports TUMT as a first-line management in this clinical setting. Thus, the requested therapy is not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 43-year-old female enrollee has requested bariatric surgery including laparoscopic banding and revision of previous gastric restrictive procedure for the treatment of her morbid obesity. Findings:  The physician reviewer found that this patients records do not document a complication of the Roux-en-Y gastric bypass procedure. In addition, the patient admits to emotional eating since the Roux-en-Y procedure and a laparoscopic gastric band placed over the bypass will not necessarily prevent such cravings. Given the patients small pouch and lack of documented follow-up, aggressive dietary and behavioral counseling with exercise would be the next appropriate step in this setting. At this time, there is a paucity of studies regarding the long-term (greater than two years) outcome of patients who have undergone revision of previous gastric bypass. Thus, the proposed procedure remains of questionable efficacy and is indicated to remedy an anatomical failure of the previous surgery. In this case, anatomical failure is not demonstrated by the records provided.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a 12-year-old female enrollee requested authorization and coverage of inpatient infusion therapy for treatment of Laundau Kleifner Syndrome.  The health plan denied the enrollees request indicating that inpatient infusion therapy 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 receiving infusions in an inpatient setting is not medically necessary, and that the health plans offer to continue providing the services through home health or in a physicians office are acceptable treatment settings for the patients needs.
Appeal type: Medical Necessity
Decision: Overturned

The parents of an eight-year-old female enrollee have requested myofunctional/speech therapy for the treatment of the enrollees oral myofunctional deficit. Findings:  The physician reviewer found that the patient has swallowing and communication impairments as a result of a congenital abnormality.  The providers evaluation provides evidence that the patients swallowing and communication impairments are secondary to impaired neuro-motor control of her swallowing and speech production musculature. This congenital abnormality results in lingual muscle weakness and faulty motor placement of this structure for chew, transport, swallow, articulation, and at-rest posturing, as documented by the patients provider. Thus, myofunctional/speech therapy services are a medically indicated and necessary intervention for this patient.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/ Case Summary:  The enrollees parent is requesting authorization and coverage for comprehensive orthodontic treatment of adolescent dentition. The enrollee has bilateral severely impacted maxillary cuspids, transversely constricted dental arches, a 100% deep and impinging overbite, and ankyloglossia with resultant tongue-thrust habit. The provider has recommended orthodontic treatment to provide the best chance of developing a healthy, functional occlusion; including attempting to successfully bring his ectopically impacted cuspids into proper occlusion. The provider indicates there is a possibility of root damage to the adjacent teeth due to the impacted cuspids, and a possibility the impacted cuspids could become ankylosed. Upon review of the record, it is evident the enrollee exhibits a significant malocclusion. The Handicapping Labiolingual Deviation (HLD) index is a tool to assess for severity of malocclusion. This index provides six specific conditions that automatically qualify a person for orthodontic care.  Additional criteria, utilizing a point system, apply if none of these initial qualifying conditions are met or selected.  For these other secondary criteria to qualify for orthodontic care a total score of 28 points is necessary. In this enrollee, the treating orthodontist claims an automatic qualifying condition of impacted permanent anteriors (canines). The record supports this automatically qualifying condition criterion is met and does support comprehensive orthodontic care. The validity of the Handicapping Labiolingual Index for assessing orthodontic need has been demonstrated through scientific scrutiny in peer reviewed journals. Reviews concludethis index is a valid and reliable determinant of need for orthodontic care.Final Result: The reviewer determined that the requested service is medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The clinical reviewer is board certified in oral and maxillofacial 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for hydrocodone 10/325 (quantity 120 pills in 30 days). Findings:  The physician reviewer found that the physician reviewer found the submitted documentation fails to demonstrate the medical necessity of the requested medication quantity. MRI showed degenerative disc disease in both her neck and low back.  However, clinical practice guidelines do not support the use of chronic opiates for neck and low back pain.  There are a multitude of other therapies available that need to be tried and documented before using chronic opiate therapy.  Further, the use of chronic opiates carries significant risk, and a formal risk/benefit assessment needs to be conducted and documented, in addition to documentation of urine toxicology screens and an opiate maintenance agreement. This is not documented in the records provided. The medical evidence does not support the requested medication quantity in this clinical setting. All told, hydrocodone 10/325 (quantity 120 pills in 30 days) is not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested medication quantity 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 anesthesiology with sub-specialty certification in pain 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 breast tomosynthesis for evaluation of her medical condition.  Findings:  Three physician reviewers found that in the peer-reviewed medical literature, Skaane and colleagues found that the addition of three dimensional digital breast tomosynthesis to two dimensional full field digital mammography resulted in a significantly higher cancer detection rate and enabled the detection of more invasive cancers. Thus, although additional studies are needed to confirm these findings, there is adequate data to support the utility of three dimensional digital breast tomosynthesis in this clinical setting. For these reasons, breast tomosynthesis was likely to be more beneficial for evaluation of this patients medical condition than any available standard therapy. Final Result: The reviewers determined that the diagnostic procedure at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications:   All three reviewers are board certified in diagnostic radiology and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for a mastopexy (breast lift).At issue is whether the requested mastopexy is medically necessary to treat the patients medical condition. Does the condition constitute an abnormal structure of the body? If so, is the abnormal structure of the body caused by any of the following: congenital effects, developmental abnormalities, trauma, infection, tumors, or disease? If so, is the requested surgery performed to do either of the following: improve function or create a normal appearance to the extent possible? If so, does the surgery provide more than a minimal improvement in the appearance of the patient?In this case, the patient has hanging breast tissue. The patient complains of a recurrent rash underneath her breasts, although physical examination at the end of January 2021 reported that no current or active rashes were noted under her breasts. The patient does not have a functional problem with the rash under her breasts that has been demonstrated to be resistant to appropriate medical treatment. Therefore, the requested mastopexy (breast lift) is not medically necessary to treat the patients medical condition.The California reconstructive surgery statute requires health insurers to cover reconstructive surgeries, defined as surgery performed to correct or repair abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease to do either of the following: (1) to improve function; (2) to create a normal appearance, to the extent possible. Breast ptosis does not constitute an abnormal structure of the body. It is a normal structural change that occurs with aging and as a result of the normal structural changes that are accommodative responses to gain or loss of body mass. Breast ptosis is not due to congenital defects, developmental abnormalities, trauma, infection, tumors, or disease. The appearance is normal and consistent with the accommodative responses to gain or loss of body mass. The patient does not have a functional problem with the rash under her breasts that has been demonstrated to be resistant to appropriate medical treatment. The California reconstructive surgery statute does not apply in this instance. Therefore, the requested mastopexy (breast lift) is not reconstructive in nature.Final Result: The reviewer determined that the requested service is not medically necessary for evaluation of the patients medical condition and not reconstructive in nature. Therefore, the Health Plans denial should be upheld.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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for custom foot orthotics/shoe inserts.Orthotics have been utilized for the treatment of painful metatarsalgia as a standard of care conservative treatment. The orthotics are used to offload pressure from the plantar forefoot. Particular accommodations may be added to the orthotic, such as a metatarsal raise pad, which further alleviates pressure from the plantar forefoot/metatarsal heads. In this case, the records document painful hammertoe contractures and metatarsalgia to bilateral feet. Therefore, the requested custom foot orthotics/shoe inserts are medically necessary for the treatment of the patients medical condition.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 podiatry 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 male enrollee has requested chiropractic care for the treatment of his neck pain. Findings:  The physician reviewer found that this patient presented to his physician with a complaint. It appears as if the patient had sought other treatment with no positive results. Chiropractic practitioners are neuromuscular specialists. X-ray report indicates that there is a subluxation present, in which alignment, movement integrity and physiological function of the spine is altered. Chiropractic care is an appropriate conservative intervention in this clinical setting and is medically indicated for treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

The enrollee requested coverage for the FreeStyle Libre 14-day system. The enrollee has type 2 diabetes mellitus (DM). His endocrinologist reports he has uncontrolled diabetes and prescribed the FreeStyle Libre 14-day system. The American Association of Clinical Endocrinologists (AACE) published a consensus statement stating that continuous glucose monitoring in type 2 DM can be useful in patients with unappreciated hyperglycemia, hypoglycemia unawareness or those at risk of hypoglycemia. Based on the information provided, this patient has no history of hypoglycemia or hypoglycemia unawareness. It is not clear how much he tried home glucose monitoring by doing finger sticks and adjusting the dose of medication to see if he is achieving improvement in his blood sugar control. The FreeStyle Libre 14-day system is not medically necessary to treat the patients medical condition. Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the enrollees medical condition.Credentials/Qualifications: The physician reviewer is board certified in 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 48-year-old male enrollee has requested for a colonoscopy for evaluation of his colon polyp.  Findings:  The physician reviewer found that if the polyp discovered and removed during the colonoscopy were proven to be an adenoma, then a repeat colonoscopy would be justified before waiting the required 7 years. However, the histology of the polyp is not documented. In addition, the patchy inflammatory changes seen on the original colonoscopy were likely due to the colon preparation itself and would not be an indication for a repeat colonoscopy.
Appeal type: Medical Necessity
Decision: Upheld

The patient has requested authorization and coverage for orthopedic evaluation of the right knee, left knee, or both knees. This patient presents with a history of chronic bilateral knee pain with associated locking and giving way. The provider recommended that the patient should lose weight prior to surgery. The records provided for review do not include documentation that the patients knees require further examination by an orthopedic surgeon. There is no evidence of a recent physical examination of the knees by the patients primary care physician. Moreover, there is no indication that the patient is ready to proceed with knee surgery at this time. There is no compelling rationale to support the medical necessity of a referral to an orthopedic specialist when continued conservative management of these complaints is within the armamentarium of the primary care physician. Therefore, the request for referral to an orthopedic specialist for the right and/or left knee is not medically necessary for evaluation of the 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: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The enrollee has requested reimbursement and prospective authorization and coverage for residential treatment center (RTC) services. The records provided for review document that this patients post-acute withdrawal symptoms were not severe in nature. She was not a danger to herself or others, she was not aggressive or violent, and was not gravely disabled. There were no emotional, behavioral, cognitive, or impulsive symptoms that would warrant services at the RTC level of care. She was medically and psychiatrically stable to the extent that she did not require a 24-hour facility to render the remainder of her care. Her medication management and anti-craving medication could have been performed in an ambulatory setting. There was no evidence of a high degree of impulsivity, agitation, depression, mania, hallucinations, or any other significant symptom that would interfere with her care. She was motivated and was noted to be working the program. She was cooperative and participating in her treatment plan. She had prior exposure to 12 step programs and had a sponsor. Although she continued to struggle with her emotions and required further treatment to continue to develop and solidify coping skills, this did not require the structured environment of a RTC setting. She could have been stepped down to an ambulatory level of care. For these reasons, the RTC services provided were not and are not medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the services at issue were not and 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 psychiatry with sub-specialty certification in addiction 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.