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

A 34-year-old male enrollee requested buprenorphine/naloxone (Suboxone) film or tablets for medical treatment of the enrollees opioid dependency. Findings:  The physician reviewer found that the limited records available for review on this patients substance abuse history do not support the medical necessity of the requested buprenorphine/naloxone (Suboxone) film or tablets. There is a lack of documentation on the patients pattern of abuse including the quantity and length of time, withdrawal symptoms, the presence of medical or psychiatric comorbid conditions, titration of Suboxone to the current dose, and the patients response to treatment. Moreover, it is unknown whether the patient has participated in prior treatments or detoxifications. Based on records provided for review, the medical necessity has not been established for the requested buprenorphine/naloxone (Suboxone) film or tablets for management of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested nerve damage graft product (Neuromend) for treatment of his medical condition.   Findings:  Two physician reviewers found that there is a lack of support for the services at issue in this clinical setting.  Based on the operative note, a conduit was used as a wrap around a primary repair.  As noted in the medical literature, there is limited scientific (animal and clinical) evidence (in the peer reviewed literature) regarding its efficacy. The material is expected to fully resorb between 4 and 8 months post implantation.  Per the medical evidence, the services at issue were not likely to have been more beneficial than other treatment options. Final Result: Two reviewers determined that 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: One reviewer is board certified in plastic surgery with sub-specialty certification in hand surgery and is actively practicing.  Two reviewers are board certified in 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

A 38-year-old female enrollee requested authorization and coverage of Botox injections. The Health Plan denied the request indicating that the requested therapy is not medically necessary for treatment of the enrollees cervical dystonia.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plans denial on the basis that the requested therapy is medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

A 64-year-old male enrollee has requested for speech therapy for treatment of her status post hemorrhagic stroke. Findings:  The physician reviewer found that aphasia is a common complication following stroke and affecting about one-third of those who experience a stroke (Brady, et al.). Speech therapy in the early aftermath following stroke, which is complicated by aphasia, is generally considered an appropriate intervention (Bernheisel, et al.), but clear evidence of efficacy of the various interventions that are typically provided is still lacking (Langhorne, et al.).the available peer-reviewed medical literature has not established that long-term formal speech therapy is clinically effective. Long-term speech therapy in the setting of chronic complications after stroke, such as cognitive impairments and aphasia, is not proven to be of clinical benefit.
Appeal type: Medical Necessity
Decision: Overturned

The mother of a four-year-old female enrollee has requested speech therapy for the treatment of the enrollees difficulty with speech articulation. Findings:  The physician reviewer found that the medical records submitted reflect a young patient with problematic speech and a mild hearing deficit.  She has difficulty with speech articulation, and thus has responded well to speech therapy.  The patients records provide objective evidence that she is making excellent progress with this therapy to date.  The patient has a condition which is known to benefit from speech therapy, and a significant benefit has been documented.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested breast tomosynthesis for the enrollees breast cancer screening.  Findings: Two physician reviewers found that Tomosynthesis was approved by the U.S. Food and Drug Administration (FDA) for clinical use in 2011. Tomosynthesis was also approved by Centers for Medicare and Medicaid Services (CMS) for reimbursement in 2014. The American College of Radiology (ACR) recommended that the technique be removed from the investigational category due to the advantages this tomographic method brings to radiologists interpreting mammograms. This procedure often allows the reader to separate dense glandular elements from underlying architectural distortion/mass resulting in a decrease in callbacks and increase in detection of small cancers. For these reasons, the addition of tomosynthesis to the usual two dimensional imaging mammographic protocol was likely of more benefit to this patient than if the examination had been performed using the two dimensional technique alone.Final Result: Two reviewers determined that the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Credentials/Qualifications: All three physician reviewers are board certified in diagnostic radiology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The patient has requested authorization and coverage for maxillofacial computed tomography (CT) scan without dye. The records provided for review document that this patient does have over-retained primary teeth with impacted permanent teeth. Given the patients prior medical history and the need for definitive surgical plan, obtaining a cone-beam CT prior will facilitate surgical planning. Two-dimensional imaging for surgical planning has several limitations, including magnification, distortion, superimposition of structures and misinterpretation. Cone-beam CT will allow the provider to determine the best clinical approach to reduce invasiveness of the surgery and will permit further appreciation of adjacent anatomy, including presence of any resorption of her adjacent teeth, which can change the treatment plan. Given these considerations, the requested maxillofacial CT scan without dye is medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested services are medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The 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 a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 60-year-old male enrollee has requested hyaluronic viscosupplementation (Euflexxa injections) for bilateral knees for treatment of his osteoarthritis. Findings:  The physician reviewer found that the usefulness of viscosupplementation in the treatment of osteoarthritis has been generally accepted,  (Bellamy and colleagues). The treatment seems more efficacious in patients with less severe arthritis, with no effusion or mild effusion (Gossec and Dougados). There is a greater lack of clarity in the case of repeated courses of treatment, with some reports indicating a favorable effectiveness and safety profile, especially in patients with a previous successful course of therapy, and others reporting increased problems with local reactions. Although repeat treatment with viscosupplementation is not uncommon, there is a lack of prospective, controlled double-blind studies to support this practice, and further studies are needed.  In this case, the patient was noted to have had a favorable prior course of treatment, but significant degenerative disease is noted, as well as the presence of synovitis.  Both findings are not favorable to a good response to viscosupplementation.  In this patients case, retreatment with hyaluronic viscosupplementation (Euflexxa injections) for bilateral knees is not medically indicated.
Appeal type: Experimental/Investigational
Decision: Upheld

A 61-year-old male enrollee requested authorization and coverage of Actimmune. The Health Plan denied the request indicating that the requested therapy is considered investigational for treatment of the enrollees idiopathic pulmonary fibrosis. Three physician reviewers performed an experimental/investigational Independent Medical Review. All three physician reviewers concluded that the requested therapy is not likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy. Because all three physician reviewers concluded that the requested therapy is not likely to be more beneficial for 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 50-year-old male enrollee has requested Actiq for treatment of his chronic pain. Findings:  The physician reviewer found that Actiq is FDA approved for use in patients with cancer pain. There is a lack of data from randomized controlled trials regarding the use of this medication in ambulatory non-malignant pain patients. Currently, the available evidence in this setting is limited to case series and individual case reports in the literature. The effectiveness of Actiq in the treatment of non-malignant pain has not yet been proven in randomized controlled trials. Studies regarding the use of rapid-onset opioids in chronic, non-cancer pain that also measure patient function are needed(article by Simon). Simon noted that other unanswered questions include the potential for an increased risk for opioid misuse, the potential for rebound pain and the potential for poorer compliance when analgesics are dosed as needed versus around the clock. All told, the current medical literature does not support the use of Actiq for treatment of this patients non-malignant pain.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 62-year-old male with hypertension (145/91) and hyperlipidemia (LDL 179) in February 2006. He has a prior history of mild aortic regurgitation and aortic valve sclerosis. His EG shows left axis deviation or left anterior hemiblock. He underwent a treadmill test in April 2006. He went six minutes on a Bruce Protocol and the test was interrupted as non-ischemic. He was again hypertensive (148/97 at rest) and had a hypertensive response to exercise (166/100). The patient underwent an echocardiogram in May 2006, which showed E to A reversal on diastolic mitral inflow tracings, septal wall thickening (1.21 cm) and mild aortic insufficiency (AI). All of these echocardiographic findings are consistent with hypertensive heart disease. The echocardiogram was read as no change from January 2002.The patients main symptom is that of dyspnea on exertion; angina or chest pain is not noted in the progress notes. The patient apparently wishes to pursue alternative management rather than medicines to treat his hyperlipidemia and systemic hypertension and therefore has requested a referral to a cardiologist for a second opinion regarding his heart disease with additional testing as needed. The patients provider has recommended treatment of hyperlipidemia and systemic hypertension as well as follow-up by echocardiogram in three years. At issue is whether the requested referral is medically necessary for treatment of the patients condition.It is within the standard of care for patients with mild aortic regurgitation, little or no LV dilation and normal LV systolic function to be followed on a yearly basis. Yearly echocardiogram is not necessary unless there is clinical evidence that regurgitation has worsened. Routine echocardiogram can be performed every two to three years in such patients. Routine re-evaluation in asymptomatic patients with mild valvular regurgitation having stable physical signs and normal LV site and function is considered Class III according to the ACC/AHA guidelines (i.e., it is not recommended). Similarly, mild aortic stenosis or sclerosis is simply observed. There is no further cardiology intervention required for this patient at this point. The recommendations of the patients provider are medically appropriate. AHA antibiotic prophalaxis can be considered along with observation unless new signs or symptoms arise.If the patient cannot achieve JNC 7 goals for systolic hypertension (140/80) or NCEP III target LDL (100-130), then pharmacologic intervention is necessary. Uncontrolled hypertension can worsen AI, and untreated hyperlipidemia can lead to CAD. His provider has recommended pharmacologic treatment and this should strongly be considered in this case particularly in light of the failure of alternative treatment and diet.For the reasons set forth above, I have determined the requested referral is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 56-year-old female who has failed conventional medical therapy. She has arthritis as a component of her comorbidities and is taking NSAIDs. The patient has obtained psychiatric clearance for weight loss surgery. She has requested authorization and coverage for gastric bypass with duodenal switch. The Health Plan has denied the patients request on the basis that duodenal switch is not medically necessary for treatment of her medical condition.The patient is an appropriate candidate for surgical intervention to treat her morbid obesity. There is more than substantial data in the literature to support the use of duodenal switch to accomplish this goal. The literature shows that duodenal switch has a superior long-term outcome when compared to Roux-en-Y gastric bypass. Consequently, duodenal switch is an accepted and medically necessary procedure for this patients medical condition. Therefore, I have determined that the requested procedure is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

The parents of a 1-year-old female enrollee have requested a Dynamic Orthotic Cranioplasty for the treatment of the enrollees condition. Findings:  The physician reviewer found that the deformity (as per neurosurgeon) had become fused, hence the patient needed therapeutic intervention to prevent deformity of her face and skull throughout her life. Using a non-surgical intervention was ideal (i.e., DOC band) with less risk to the patients life. The Health Plan has suggested head positioning and exercises. These would not work in a patient who does not lie still constantly. That would have been more appropriate for a child with developmental delays. Moreover, the patient had torticollis which definitely makes it more difficult for her to lie on the opposite side. The successful completion of DOC band confirms the appropriate method of therapy was used in this case.
Appeal type: Medical Necessity
Decision: Overturned

The parent of an enrollee has requested reimbursement and authorization and coverage for 40 hours per week of home health care services.The peer-reviewed medical literature related to care of children with severe static encephalopathies that include cerebral palsy confirms that skilled nursing may be medically necessary for children with complex medical problems that relate to profound intellectual disabilities and grossly impaired motor functions. Medical literature reports a systematic review and meta-analysis of multiple databases and found that there is increased risk for malnutrition, dehydration, aspiration pneumonia, and poor quality of life in persons with cerebral palsy. In this case, the patient has both profound intellectual disabilities and grossly impaired motor functions, she is at constant risk for aspiration, and because she is not mobile, she is also at risk for integument breakdown as well. If the patients deficits were less profound, than perhaps family members could assume these responsibilities, but the patients deficits are significant and her risks of malnutrition, aspiration and pressure sores that could lead in turn to systemic infections are very high. Under these circumstances, 40 hours of home health care services per week were, and are, medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the services at issue and requested services were, and 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 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: Medical Necessity
Decision: Overturned

The patient is a seven-year-old male with a diagnosis of pervasive developmental disorder (PDD). The patient has been receiving speech therapy for receptive and expressive language delay associated with PDD. The patients mother has requested authorization and coverage for continued speech therapy. The Health Plan has denied this request on the basis that continued speech therapy is not medically necessary for treatment of the patients medical condition.The submitted documentation demonstrates the patient has been diagnosed with PDD by his treating physician. Review of the submitted speech therapy evaluation demonstrates the patients therapy has been directed at treatment of PDD rather than the limited diagnosis of phonological disorder. Furthermore, it appears the patients condition has improved with speech therapy and that he is likely to continue to benefit from speech therapy. Therefore, I have determined the requested therapy is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned. The patient should continue to receive speech therapy once a week for a period of six months with re-evaluation at the end of the six-month period.
Appeal type: Medical Necessity
Decision: Upheld

A 28-year-old female enrollee has requested the Exogen Bone Healing System for treatment of her ankle pain. Findings:  The physician reviewer found that despite frequent clinical usage of ultrasonic bone stimulation for promoting bone healing, including in delayed post-operative union, this treatment has not yet been proven to be efficacious. In this patients case, where the etiology of her symptomatology has been unclear and no bony fracture has been demonstrated, the expectations of significant, sustained benefit with this treatment would not have been significant.  All told, the Exogen Bone Healing System was not medically indicated for this patient.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 55-year-old female with symptomatic breast problems. Multiple lesions of the left breast recently biopsied have left a deficit of breast tissue. The patient also has ptosis of the contralateral breast. The pathology review of the removed tissue did not find the suspicious atypical cells noted on the aspiration biopsy and therefore, the breast is not cleared and potentially will require future biopsy. Because of the asymmetry, the patient sought consultation with a board certified plastic surgeon who examined her both before and after the left breast biopsy. The plastic surgeon recommended the patient undergo reconstructive procedures to restore normal breast symmetry. Photocopies of pictures of the patient in March 2003 and May 2004 demonstrate marked changes in the size and contour of the left breast. The Health Plan has denied the recommended surgery as cosmetic in nature and not medically necessary.Review of the submitted evidence reveals the requested surgery is reconstructive rather than cosmetic in nature. The patient has a defect resulting from fibrocystic disease (a tumor) and its excision. Breast reconstruction surgery has been requested to restore the patient to a normal appearance to the extent possible. The procedures proposed are not cosmetic in nature, but are considered reconstructive as defined by California law and the guidelines of the American Society of Plastic Surgeons. Therefore, I have determined that the requested surgery is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 64-year-old female who presented with left sided chest pain and coughing with rib tenderness for which her primary care provider (PCP) ordered a chest CTA.  No records previous to the chest CTA in December 2005 were included in the review.  There is however a note from January 2006 indicating the patient was hypertensive (146/76), had a negative review of respiratory symptoms, and had mild, relapsing left chest wall tenderness to palpation (which had originally started in May 2005). The patient has requested reimbursement for the cost of the CTA.  The Health Plan denied her request based upon a determination that CTA was not medically necessary to evaluate for possible pulmonary embolism.There is no record of tachycardia, hypoxia, or predisposing risk factors for deep vein thrombosis (DVT) or pulmonary embolus (PE) found in the record. The patients history and physical examination after the chest CT revealed mild chest wall pain with palpation but no symptoms of respiratory distress or tachycardia. This constellation of findings would make pulmonary embolus very unlikely and would more often indicate musculoskeletal chest wall pain. Therefore, I have determined the CTA at issue was not medically necessary for evaluation of the patients medical condition. The Health Plans denial should be upheld.