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

Nature of Statutory Criteria/Case Summary:   An enrollee has requested a medical device (Willow Curve) and a referral to an orthopedic specialist for treatment of his shoulder pain.   Findings:  The physician reviewer found that the requested medical device, Willow Curve, is not medically necessary for treatment of the patients medical condition. The Willow Curve is a device which emits photonic and thermal kinetic energies. The efficacy of this device beyond placebo effect is not supported by the medical literature. In sum, the Willow Curve device is not medically necessary in the management of this patients medical condition. However, a referral to an orthopedic specialist is medically necessary for evaluation of the patients medical condition. An orthopedic specialist is clinically indicated to clarify the causes for the patients shoulder pain so treatment protocols can then be determined. All told, the request for a medical device (Willow Curve) is not medically necessary; however the request for a referral to an orthopedic specialist is medically necessary for treatment of the patients shoulder pain.  Final Result: The reviewer determined that a portion of the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned.  Credentials/Qualifications: The reviewer is board certified in orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the graft procedure, Kerecis Omega3. Findings:  Three physician reviewers found that Kerecis Omega3 is a tissue-based, skin-substitute wound care product that has been used in perioperative and chronic wound care. In this case, the patient had a full thickness, venous stasis ulcer which was located over the ankle. To date, large scale prospective clinical trials have not been performed to compare the efficacy of Kerecis Omega3 to other biologic skin substitutes versus existing wound therapies. As such, Kerecis Omega3 was not likely to have been superior over other available treatment options. Final Result: The 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: Physician reviewers 1, 2 and 3 are board certified in surgery 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

Nature of Statutory Criteria/Case Summary:  An enrollee has requested intensive outpatient program level of behavioral health services for treatment of her behavioral health condition.   Findings:  The physician reviewer found that intensive outpatient services were not and are not medically necessary for treatment of the patients medical condition. According to the documentation submitted for review the patient was not in withdrawals.  She was not a threat to herself or others. She was psychiatrically and medically stable. She had improved and was gaining skills towards her recovery. She no longer required the frequency or intensity of an IOP program and her treatment could have continued on an outpatient basis with concomitant community based support from a 12-step program. As such, intensive outpatient program level of behavioral health services was not and is not medically necessary. 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 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 parent of a male enrollee has requested authorization and coverage for speech therapy. Findings: This patients records do not include a thorough evaluation for autism spectrum disorder. If the patient is found to meet the criteria for autism, then applied behavioral analysis (ABA) therapy would be indicated. Medical literature noted that treatment with speech therapy shows benefits in expressive language. However, there are fewer benefits in receptive language. Although children with language delays require speech therapy, this patient may require special education or ABA therapy to help him obtain the skills to be able to participate in speech therapy. Thus, the requested speech therapy is not medically necessary for treatment of this patients language delay at this time. 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 at this time. Credentials/Qualifications: The reviewer is board certified in pediatrics 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 70-year-old male enrollee has requested for a computed tomography scan of the chest and lungs for evaluation of his pulmonary nodule and weight loss.  Findings:  The physician reviewer found that MacMahon and colleagues discussed the well established role of radiographic studies in the evaluation of pulmonary nodules as set forth by the Fleischner Society. Vanderschueren and colleagues suggest that, Simple, non-invasive screening tests, embarking from thorough history-taking and clinical examination, are advocated first. The authors suggest that additional testing should be directed towards areas of concern raised by this initial evaluation. Thus, a provider should perform a thorough history and physical, and order appropriate laboratory studies including basic chemistry panels and blood counts, prior to considering radiographic evaluation for involuntary weight loss. The records fail to discuss whether the patient experienced any further symptoms or what basic evaluations were performed other than a series of tumor markers and hormone level testing
Appeal type: Medical Necessity
Decision: Upheld

Findings:  The physician reviewer found that an enrollee has requested authorization and coverage for Vyvanse 10 mg one tablet daily. Overall, there is a lack of documentation to support a diagnosis of ADD in this patients case. Documentation does not provide detailed ADD symptomatology targeted by the Vyvanse, such as inattention, lack of focus, poor concentration, interrupting others, or inability to complete tasks. Further, the note lacks any report of efficacy of the Vyvanse on such symptoms. All told, the requested Vyvanse 10 mg one tablet daily is not medically necessary for treatment of this patients medical condition. 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 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: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested bilateral foot orthotics for treatment of his medical condition.  Findings:  The physician reviewer found that there is sufficient support for the requested equipment in this patients case.  The patient has congenital abnormalities in his foot architecture bilaterally which appear consistent with pes cavus. He is reporting significant foot pain with a sense of bilateral foot dislocation, causing functional difficulty in activities of daily living. There is imaging evidence of a high intermetatarsal angle with medial sesamoid fracture. He has utilized orthotics since childhood and the previous orthotics were reported as not currently effective. Custom molded orthotics by the podiatrist to stabilize the current fracture and address the structural abnormalities is consistent with current evidence-based literature. Therefore, the requested bilateral foot orthotics are medically indicated for the treatment of this patient. 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 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 patient has requested authorization and coverage for 30 minutes of general anesthesia (CDT D9222 and D9223) for a surgical tooth extraction. Per the American Dental Association (ADA), moderate sedation is appropriate for patients with obesity, or American Society of Anaesthesiologists (ASA) scores of III or IV, especially when associated with airway-associated morbidities. The ADA noted that deep sedation or general anesthesia is supported for mentally or physically challenged patients. The American Academy of Pediatric Dentistry (AAPD) states that general anesthesia may be indicated for patients who cannot cooperate due to a lack of psychological or emotional maturity and/or mental, physical, or medical disability; patients for whom local anesthesia is ineffective because of acute infection, anatomic variations, or allergy; the extremely uncooperative, fearful, anxious, or uncommunicative child or adolescent; patients requiring significant surgical procedures; patients for whom the use of general anesthesia may protect the developing psyche and/or reduce medical risk; and patients requiring immediate, comprehensive oral/dental care. In this case, the patient requires surgical tooth extraction and bone grafting. She reports anxiety and fear related to the planned procedure. The records provided for review do not document an ASA classification score of III or IV, evidence of a difficult airway, or an AAPD indication to support general anesthesia for the surgical extraction and bone grafting. Moreover, the provider did not document that there were previous attempts to complete the planned dental procedures with mild or moderate sedation. Based on the medical records available for review and the current national guidelines, the requested 30 minutes of general anesthesia (CDT D9222 and D9223) for a surgical tooth extraction is 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.
Appeal type: Medical Necessity
Decision: Overturned

A 26-year-old female enrollee requested authorization and coverage of a lefort osteotomy and bilateral mandibular sagittal split osteotomies. The Health Plan denied the request indicating that the requested procedures are not medically necessary for the treatment of the enrollees temporomandibular joint dysfunction.One oral surgeon reviewer performed a medical necessity Independent Medical Review. The oral surgeon reviewer overturned the Health Plans denial on the basis that the requested procedures are medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/ Case Summary:  The enrollees parent has requested authorization and coverage for occupational therapy using sensory integration therapy once a week and normal occupational therapy (OT) once per week. According to the enrollees medical record, this enrollee is diagnosed with Attention Deficit Hyperactivity Disorder (ADHD) and Sensory Processing Disorder. His parent reported that the enrollee was having behavioral issues at school such as over stimulation, mimicking other children and being troublesome and disruptive in class. Previously, he did fine in a smaller group of children and the issue had started when he was sent to a bigger group. He was fine when with his parents. The enrollee could not sit still in the classroom, but his father did not want to start him on medications. The enrollee did not have problems learning or doing what he was told to do, but could not focus for long. The enrollee was diagnosed with Attention Deficit Hyperactivity Disorder and was said to be sensitive to noise. The enrollee was seen by occupational therapy for evaluation of motor skills, which was found to be fine. His father states his son has difficulty in loud or crowded places and is causing an issue for him to have a successful career in school. According to the medical literature, there is no universally accepted framework for diagnosis and sensory processing disorder generally should not be diagnosed. Children with a range of neurodevelopmental and behavioral disorders, including attention-deficit/hyperactivity disorder (ADHD), autism spectrum disorder (ASD), and anxiety disorders have symptoms of sensory processing disorder. A review of the peer-reviewed medical literature found no role for the use of occupational therapy to treat Attention Deficit Hyperactivity Disorder or Sensory Processing Disorder in the absence of a substantiated deficit in fine motor skills. In this case, average fine motor precision, fine motor integration and manual dexterity were found. The medical literature identified few positive effects were found in sensory-based intervention studies and suggest interventions may not be effective.Final Result: The reviewer determined that the service at issue is not medically necessary for treatment of the enrollees condition. Credentials/Qualifications: The physician reviewer is board certified in Pediatrics and Pediatric Developmental Medicine and is actively practicing.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for digital breast tomosynthesis. Findings:  Three physician reviewers found that breast tomosynthesis is a technique that was developed several years ago as a problem solving adjunct to routine mammography. Applying the same basic concept as computed tomography scanning, the logic is that by separating the various layers of breast tissue, one can better detect abnormalities. This has been shown to be most useful in the evaluation of dense breasts. In this patients case, her breasts were reported as being heterogeneously dense. It is specifically those patients who have dense breasts that can benefit most from digital breast tomosynthesis. The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor. Final Result: Three reviewers have determined that the service 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 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

Nature of Statutory Criteria/Case Summary: The patient has been diagnosed with attention deficit hyperactivity disorder (ADHD) and anxiety disorder. The patient reported difficulty sustaining attention. The records noted difficulty in school. The provider noted that the patient exhibited signs of hyperactivity, restlessness, and fidgeting. In the Independent Medical Review Application/Complaint Form, the patients parent reported the patient had a binge eating disorder, suicidal ideation, and episodes of self-harm via cutting. The patient appeared to be stressed and unhappy. The patient denied suicidal ideation. The patient reported panic attacks, paranoia, and vomiting to stay thin. The patients parent has requested authorization and coverage for a one-year supply of Vyvanse 20 mg. The Health Plan denied the request and reported the requested medication is not medically necessary for the treatment of this patient. At issue in this case is whether a one-year supply of Vyvanse 20 mg is medically necessary for the treatment of this patients medical condition. Researchers reported, Binge eating disorder in adolescents was highly comorbid with attention deficit hyperactivity disorder, mood and anxiety disorders, and severe obesity. Authors reported that Vyvanse is currently the only drug to be approved in the United States for the treatment of moderate to severe binge eating disorder (BED) in adult patients. Najib reported, The chronic nature of ADHD extends well beyond childhood and, in adolescents, may lead to a variety of risk-taking behaviors, which can have a significant adverse consequence for development and adult well-being. Lisdexamfetamine, a prodrug of d-amphetamine, is a once-daily medication indicated for the treatment of ADHD in children and adolescents. In this case, the patient has been diagnosed with ADHD. The patient was noted to have a history of binge eating disorder. The medical evidence supports the requested medication in this clinical setting. Therefore, a one-year supply of Vyvanse 20 mg is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in pediatrics 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 requested authorization and coverage for buprenorphine (Butrans Patch 5 mcg). Researchers performed a meta-analysis comparing the results of 33 studies evaluating the safety and efficacy of buprenorphine in the treatment of patients with chronic pain. The authors concluded that the current clinical and long-term safety data support the use of buprenorphine over full mu-opioid receptor agonists for the effective and preferential treatment of chronic pain at a critical time when safer and less addictive treatments are needed. In this case, the patient has chronic neck pain with radicular features and cervical canal stenosis at C5-6 and C6-7 confirmed on magnetic resonance imaging (MRI). She has tried and failed multiple conservative treatment options. A recent evaluation by neurosurgery recommended artificial cervical disc replacement at the affected levels. Her pain management provider has recommended a low dose buprenorphine patch for treatment of her chronic neck pain due to previous intolerances to full opioid agonists in the past. Current peer-reviewed medical literature validates the efficacy of buprenorphine for use in chronic pain population and current consensus guidelines support using buprenorphine as first-line treatment over traditional full opioid agonists due to better safety profile, tolerability and non-inferior analgesic effects. Given this support, the requested buprenorphine (Butrans Patch 5 mcg) is medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in anesthesiology with subspecialty certification in pain management 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 Sovaldi and ribavirin for treatment of the enrollees chronic hepatitis C virus genotype 1a and 2b.  Findings: The physician reviewer found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. This treatment guideline applies regardless of fibrosis stage or viral load. Per guidelines, when multiple genotypes are present, therapy should be chosen to maximize efficacy against each genotype. In this case, the patient was already treated with Sovaldi and Ribapak, as Sovaldi is a component of the Harvoni that was provided. Thus, the patient was appropriately treated for genotype 1 hepatitis C with Harvoni (Kowdley, et al). The genotype 2 infection may be cured, as Sovaldi with Ribapak can cure genotype 2 infection in cirrhotic patients (Zeuzem, et al). The patients viral load testing should be performed after treatment concludes in order to establish if has been cured. However, this information is not provided for review. Additionally, the requested regimen of Sovaldi and ribavirin for 12 weeks is no longer recommended by the AASLD and IDSA guidelines as an appropriate regimen for genotype 2 hepatitis C, as alternatives have proven statistically superior in effectiveness. In summary, evidence of ongoing hepatitis C infection is not provided, and the requested regimen would not be appropriate even if this patients hepatitis C persisted. For these reasons, the requested Sovaldi 400 mg tablet and ribavirin 600 mg tablet are not supported as medically necessary.Final Result: The reviewer determined that the requested medications 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 internal medicine with sub-specialty certification in gastroenterology 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.