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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for intravenous immunoglobulin (IVIG) therapy for treatment of the enrollees medical condition. Findings:  The physician reviewers found that the patient presents with a non-length dependent small fiber sensory neuropathy as documented by skin biopsy and diffuse neuropathic pain. The patient suffers from moderate to severe pain which has partially responded to some of the medications including opiates. In this clinical setting, it is vital to determine an etiology and evaluate certain markers. Elevated spinal fluid protein and possible presence of oligoclonal banding suggests an underlying autoimmune etiology. The documentation submitted for review does not support an autoimmune etiology. The patient has not had a spinal fluid analysis. Furthermore, non-length dependent small fiber sensory neuropathy is rare and there are only small open label retrospective reports of treatment cited in the medical literature. Some patients responded to oral anticonvulsant type medications, but the patients often require a combination of three different therapies to obtain a good response. A good response to prednisone in some patients and others who did respond to IVIG. Immunotherapy be reserved for patients who have failed standard therapy and have evidence of autoimmunity. This patient has not yet tried several of the standard therapies including a combination that contains amitriptyline, and corticosteroids. Final Result: Two of three reviewers determined that the requested medication 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: Physician reviewers number one, two, and three are board certified in neurology and 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

An enrollee has requested authorization and coverage for a Quantum Q6 Edge 3.0 wheelchair with requested accessories. The submitted documentation does not support that the requested power mobility device is medically necessary. The medical literature identifies that the disease is progressive and that adaptive equipment must be modified with time. In this case, the submitted medical records do not reflect that the requested wheelchair will enable the patient to perform activities of daily living in the home. Records indicate that the patient requires maximum assistance, or total care, to complete activities of daily living and that the patient has caregiver assistance. The submitted records include a DME consultants evaluation of the mobility needs of the patient which states that their needs can be met with an alternative device such as a manual wheelchair with tilt in space and appropriate positioning components, and that the requested power mobility device will not change the patient's ability to participate in the completion of his activities of daily living. Under these circumstances, the requested Quantum Q6 Edge 3.0 wheelchair with requested accessories is not medically necessary to treat their medical condition.Final Result: The reviewer determined that the requested equipment is not medically necessary to treat the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in physical medicine and rehabilitation, with subspecialty certification in neuromuscular 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for genetic testing, CADASIL Lab Test. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  The documented neurologic examination is unremarkable, and the medical record does not adequately develop the clinical suspicion of autosomal dominant stroke in the family history in a relatively young person with or without migraine or dementia.  This patients MRI lacks abnormalities in the temporal lobe more specific for CADASIL.  Since there is no adequately documented family history and similar vascular changes can occur in chronic migraine, the medical necessity of the requested services has not been established. Final Result: The reviewers determined that the requested services are not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The physician reviewer is board certified in 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: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for laser hair removal for treatment of the enrollees gender dysphoria.Findings:  The physician reviewer found that facial hair removal is within accepted standards of practice and clinically appropriate for treatment of gender dysphoria. Excessive facial hair in a female would be considered abnormal and is referred to as hirsutism. Hirsutism is a medical condition where terminal hair grows in female in areas that are normally found in males. This would include the face, and parts of the genitalia. A female would be expected to have terminal hair in the scalp, axilla and on the arms and legs. This patients excessive facial hair is more consistent with the male gender. Additionally, the records noted that hormone therapy has not been effective in improving this patients medical condition. Therefore, laser hair removal is medically necessary for treatment of this patients gender dysphoria. With regard to whether the requested services are considered reconstructive in nature, excessive facial hair in a female is an abnormal body structure.  Hirsutism is a condition that is congenital in that the hair growth is determined by the genetic and hormonal make-up of the patient. As such, the requested facial hair removal can provide substantial improvement in the appearance of terminal hair and create as normal an appearance as possible in this patient. Moreover, the requested services are going to improve emotional function for this patient. All told, laser hair removal is reconstructive in nature. Final Result: The reviewer determined that the requested services are medically necessary and are 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 dermatology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee requested intensive outpatient program (IOP) services for treatment of his behavioral health condition.  Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the requested services. The patients problems appear to be chronic in nature including social difficulties. These issues are not an appropriate focus for IOP treatment but better handled on an outpatient basis. It does further appear that the patient did respond to the treatment that was provided, which included access to various groups and medication management. The requested services are not medically necessary for treatment 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 psychiatry 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 60-year-old male enrollee has requested SoundBite prosthetic hearing system for treatment of his unilateral hearing loss. Findings:  Two physician reviewers found that the requested device is likely to be more effective for this patient than other available options. The medical records submitted for review indicates that the patient has single-sided deafness. The SoundBite device has been U.S. Food and Drug Administration (FDA) approved for the treatment of single-sided deafness. According to the medical literature cited above, a number of clinical trials have shown its effectiveness and long-term safety. Given the support in the medical literature cited above and the documentation submitted for review, SoundBite prosthetic hearing system is likely to be more beneficial than any standard treatments for this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 64-year-old female enrollee requested authorization and coverage of medication Fosamax at 70mg weekly for the treatment of osteoporosis. 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 medication is not medically necessary for treatment of the enrollees medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/ Case Summary:  The enrollee has requested reimbursement for the nasal and sinus debridement services post-endoscopic sinus surgery. He had a severe septal deviation causing 80-90% nasal airway obstruction, and turbinate hypertrophy that caused him to suffer persistent sinusitis. When his chronic condition failed aggressive medical therapy that included multiple trials of antibiotics and oral/nasal steroid, he underwent nasoseptal reconstruction, endoscopic bilateral anterior ethmoidectomy, endoscopic bilateral maxillary antrostomy, endoscopic left sphenoidotomy, and submucous resection of the inferior turbinates bilaterally as well as repairs of nasal vestibular stenosis. On the enrollees subsequent visits with his surgeon, he underwent nasal endoscopy. However, the medical records were handwritten and illegible and do not support the medical necessity for the nasal and sinus debridement services on those visits. The American Academy of Otolaryngology and medical literature support the nasal and sinus debridement for patients who undergo debridement during the postoperative period for patients whose physical exam shows possible crusting, or devitalized bone or mucosa to enhance healing. However, there is insufficient evidence in the record to support the medical necessity of the procedures on the dates in question. Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The reviewer is a board certified otolaryngologist, 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

This patient is an eight-year-old male with a developmental delay with poor speech, and poor fine and gross motor skills affecting dressing skills, oral motor/feeding skills, toileting/bathing, grooming and hygiene. In addition, the patient has poor social skills with difficulties in school including difficulty with multistage instruction inattentiveness or distractibility. The submitted speech evaluation also documents that the patient has fleeting eye contact and abnormal pragmatic and social communication. A history of cranial birth injury is discussed in multiple places but no documentation has been provided. The patient also has a history of chronic otitis media, but no documented hearing loss. A request has been made for coverage for occupational therapy. The Health Plan has denied this request on the basis that the requested therapy is not medically necessary for treatment of the patients medical condition. While the issues of speech abnormality and auditory processing have been well documented in this case, the causes for the developmental delays in fine motor and gross motor skills including age appropriate activities of daily living are less well defined. The literature regarding auditory processing disorder is sparse and it is in question as an individual diagnosis. Rather, it is likely that it is on a spectrum of disorders. This is especially true in cases such as this in which pragmatic speech and communication delays coexist. Based upon the information provided, a neurologic reason has not been demonstrated as the cause of the patients delays. In the absence of a more specific diagnosis the requested therapy is not medically necessary. Neuropsychological developmental testing by a pediatric neuropsychologist and developmental pediatrician would be appropriate to fully evaluate the patients developmental disorders. Based upon the information set forth above, I have determined that 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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for acute rehabilitation services including speech therapy and occupational therapy through telehealth conferencing, four hours per day, five days per week. Functional impairments due to acquired brain insults such as stroke can range from mild to profound. While natural recovery evolves with time, many impairments are addressable by compensatory measures and directed rehabilitation efforts. Most of the significant neurological and functional recovery following a stroke occurs in the early stages after stroke and gains are slower in the subsequent stages. The records provided for review document that this patient was admitted to the hospital with acute left thalamic and left posterior parietal embolic infarcts. The patient is independent with all of his activities of daily living and with mobility and required supervision for bathing. While the patient has some coordination deficits and weakness, he is independent to supervision for basic self-care and household mobility. Additional rehabilitation services on an intermittent basis in the community are appropriate. Furthermore, the records do not demonstrate that the patient requires rehabilitation services for four hours per day or that this intensity of services is likely to provide a substantial benefit over standard rehabilitative care. All told, the requested acute rehabilitation services including speech therapy and occupational therapy through telehealth conferencing, four hours per day, five days per week are not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in physical medicine and rehabilitation and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a pneumatic compression device. The principal therapies for confirmed cases of lymphedema include skin care, compression garments, intensive bandaging, and lymphatic massage. Complete decongestive physiotherapy is an effective treatment for both primary and secondary lymphedemas. The management of lymphedema includes three phases: an initial treatment that aims to reduce volume of the lymphedema; a maintenance phase to maintain the result; and a withdrawal phase. These therapies approach a 70% reduction in edema burden and in compliant patients and success is maintained in greater than 80%n of patients treated. One specific contraindication to compressive therapy is the presence of arterial disease. This patient was found to have arterial and venous insufficiency. Thus, treatment should include weight loss and interventions to improve arterial and venous disease. All told, the available documentation does not support the requested pneumatic compression device as medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the requested device 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 surgery with subspecialty certification in general 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: The patient has been diagnosed with right knee osteoarthritis. The patient reported right knee pain. The physical examination findings included antalgic gait and right knee medial joint line tenderness. It was noted the patient has been treated with meloxicam, steroid injections, and physical therapy, without long-term benefit. The patient has requested reimbursement for a Durolane injection in the right knee. The Health Plan denied the request and reported the service at issue was not medically necessary for the treatment of this patient. At issue in this case is whether a Durolane injection in the right knee received was medically necessary for treatment of the patients medical condition. Review of the current medical literature pertaining to viscosupplementation reveals mixed results. Although viscosupplementation may relieve knee pain in some patients with osteoarthritis, it is unknown which patients will benefit. Considering the foregoing, viscosupplementation can only be recommended for patients with a history of lasting benefit from prior injections and in carefully selected cases when everything else has been tried and the options are limited. In this case, the patients options were limited. The patient had tried and failed other conservative treatments, including meloxicam, corticosteroid injections, and physical therapy, with the alternative being a total knee arthroplasty. The medical evidence supports the service at issue in this clinical setting. Therefore, a Durolane injection in the right knee received was medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested service 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 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: Overturned

The parent of a five-year-old male has requested authorization and coverage for speech therapy, and occupational therapy for treatment of his medical condition. Findings:  The physician reviewer found that the medical literature supports both speech therapy and occupational therapy in the autistic population. Concerning the requested speech therapy, the report by Myers, et al. is frequently cited in the autistic literature as a definitive source for the evaluation and treatment of autistic children. It is concluded in this report that, people with autism spectrum disorders (ASDs) have deficits in social communication, and treatment by a speech-language pathologist usually is appropriate. Most children with ASDs can develop useful speech, and chronologic age, lack of typical prerequisite skills, failure to benefit from previous language intervention, and lack of discrepancy between language and IQ scores should not exclude a child from receiving speech-language services (Myers, et al.). Myers, et al. recommends the modality, although the authors also note there is a paucity of literature concerning occupational therapy in the treatment of autism. However, subsequent to this report, Case-Smith and Arbesman compiled a meta-analysis of the literature, documenting the value of occupational therapy in the autistic childhood population. Further, Pfeiffer, et al. found that occupational therapy is an efficacious therapy for reducing many of the unwanted mannerisms associated with autism.The patient appears to be an excellent candidate for both speech therapy and occupational therapy.
Appeal type: Experimental/Investigational
Decision: Upheld

A 45-year-old female enrollee has requested for two-level artificial disc replacement for treatment of degenerative disc disease.  Findings:  Three physician reviewers found that The Health Plan is correct that the proposed procedure is experimental. Although the artificial disc is currently being investigated for single level disc replacement in the treatment of degenerative disc disease in the lumbar spine, there is no evidence supporting the safety and efficacy of a two-level disc replacement. Current data for single level disc replacement demonstrates that although many of the procedures may be successful in the short term, the long-term outcomes are unknown and complications may be severe.