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

The patient is an 18-year-old male who has undergone tibial eminence fracture surgery. A custom knee brace has been requested as prophylactic treatment against further injury during sports activities. The Health Plan has denied this request indicating that a functional brace used on a prophylactic basis is not medically necessary for the patient.A custom knee brace is not medically necessary for the patient. It has not been clearly established that custom braces offer any additional advantages over standard braces. Thus, a custom brace is not medically indicated. However, given the patients level of physical activity, a standard ACL brace should be authorized. Therefore, I have determined that although a custom knee brace is not medically necessary for treatment of the patients medical condition, a standard ACL brace is medically necessary and should be authorized. The Health Plans denial should be partially overturned.
Appeal type: Medical Necessity
Decision: Overturned

A 36-year-old female enrollee requested authorization and coverage of BRCA testing. The Health Plan denied the request indicating that the requested genetic testing is not medically necessary for evaluation of the enrollees medical condition.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plans denial on the basis that the requested genetic testing is medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

A 39-year-old female enrollee has requested a continuous glucose monitor for treatment of her diabetes, type 1.  Findings:  The physician reviewer found that in this case, the patient has not shown that she is having severe lows or hypoglycemic episodes. Although she is in situations where she may not be able to measure her blood glucose, it is not indicated in the records that these situations have previously resulted in adverse outcomes. Furthermore, since her A1C test has been in the 6s in 2010(6.2), 2011(6.6) and 2012(6.4), and she has not had severe lows per the submitted records, this implies that  her work and activities do not seem to be impacting her overall glycemic control.  All told, the patient appears to have well controlled blood glucose levels, despite her active lifestyle and work circumstances. Therefore, the use of a continuous glucose monitor in this clinical situation is not within the standards of medical and endocrinologic care.
Appeal type: Medical Necessity
Decision: Upheld

A 41-year-old female enrollee requested authorization and coverage of a bilateral brachioplasty, and excision of excess lateral thigh and buttock skin. The Health Plan denied the request indicating that the requested procedures are not medically necessary for treatment of the enrollees excess skin.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested services are not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

A 46-year-old female enrollee has requested for compound Lidocaine gel for treatment of her nerve pain. Findings:  The physician reviewer found that the compound Lidocaine gel is not deemed therapeutically equivalent to the Lidoderm patch which is approved by the FDA. The literature submitted pertains to the Lidoderm patch and not to Lidoderm gel. There is no evidence in the literature to support the use of the gel in this medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a 1-year, 11-month-old female enrollee has requested coverage for 6 doses of Synagis injections for treatment of her asthma.  Findings:  The physician reviewer found that there are a number of risk factors that increase the chance of morbidity from RSV disease in infants born prematurely, up to 12 months of age. The most prominent of these factors is a birth weight less than 2500 grams as noted by Holman and colleagues. According to the American Academy of Pediatrics (AAP), older infants who are still less than 24 months of age are considered high-risk if they carry a diagnosis of chronic lung disease or hemodynamically significant heart disease. Thus, while this ex-premature female patient may have been an appropriate candidate for Synagis last RSV season, she currently does not meet the published criteria or fall within a high-risk population based on the scientific studies. Accordingly, the requested Synagis for RSV prophylaxis is not medically necessary for this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

A 53-year-old female enrollee has requested extracorporeal shock wave therapy for treatment of her plantar fasciitis.  Findings:  Two physician reviewers found that review of the relevant scientific literature reveals some evidence that extracorporeal shock wave therapy can provide a moderate degree of pain relief in selected patients with chronic plantar fasciitis who have failed appropriate conservative therapy. However, optimal treatment parameters have not been established, patient selection criteria have not been adequately defined and there is a lack of information regarding the durability of treatment effect or long-term adverse effects of this treatment. In addition, there have been some conflicting results among the randomized controlled studies, thus raising concerns about the effectiveness of extracorporeal shock wave therapy for patients with plantar fasciitis. At this time, the peer-reviewed literature has not established that the services at issue are more beneficial than available standard therapy for the treatment of this patients condition.  Thus, extracorporeal shock wave therapy was not likely to be more beneficial than other treatment modalities for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

A 23-year-old female enrollee has requested Remicade, or in the alternative, Humira for the treatment of her pulmonary fibrosis. Findings:  The physician reviewer found that treatment with anti-TNF medications has not been established to be indicated or medically necessary for this patient. The submitted records do not provide confirmation of the diagnosis of idiopathic pulmonary fibrosis. Based on the information provided, it appears the patient has nonspecific interstitial pneumonitis associated with dermatomyositis. There is no convincing evidence in the medical literature of the effectiveness of anti-TNF treatment for this patient's condition, and there are case reports suggesting the possibility of pulmonary complications from these treatments. In the paper by Dastmalchi and colleagues, 13 patients with refractory myositis were treated with infliximab (Remicade) infusions. Of the 9 patients completing this study, 3 patients discontinued the drug due to adverse events, and 1 because of a malignancy. There was no strong indication of drug effectiveness in the 9 patients who were able to complete the study. Ostor and colleagues describe 5 patients with rheumatoid arthritis treated with Remicade who developed pulmonary complications, and advise caution in the use of anti-TNF therapy in patients with rheumatoid arthritis with significant underlying lung disease. Furthermore, there is one report of a patient developing polymyositis while being treated for rheumatoid arthritis with Remicade (see Musial and colleagues). As such, there is insufficient evidence of the safety and efficacy of anti-TNF inhibitors such as Remicade and Humira to support their use in this setting.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the genetic testing for cancer susceptibility. Findings:  The physician reviewers found that according to the National Comprehensive Cancer Network (NCCN) guidelines, patients who are meeting one or more of these criteria warrants further personalized risk assessment, genetic counseling, and often genetic testing and management. In this case, the patient has a maternal grandmother who is a third degree relative diagnosed with breast cancer at age 72. This patient has two daughters who are second degree relatives, one of whom was diagnosed with breast cancer at age 47, the other diagnosed with ovarian cancer at age 26. Thus, the NCCN criteria are met in the patients maternal grandmother and the patient meets criteria for BRCA1 and BRCA2 testing based on NCCN guidelines that pertain to family history. However, the patients family history does not support an indication for any of the additional testing performed on the date of service in question. Given these findings, the BRCA1 and BRCA2 mutation testing performed was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: 2 of 3 reviewers determined that a portion of the testing 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 partially overturned. Credentials/Qualifications: All three physician reviewers are board certified in clinical genetics and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A female enrollee requested rectal sensory testing (91120) for medical evaluation of her slow transit constipation, abdominal pain, non-ulcer dyspepsia, and rectocele.   Findings:  The physician reviewer found that currently, the medical literature does not support an indication for rectal sensory testing in evaluation of this patients symptoms and complaints. Remes-Troche and colleagues performed stepwise graded balloon distensions of the rectum in 30 patients with constipation and rectal hyposensitivity and in 23 healthy controls and evaluated the thresholds for first sensation, desire, and urgency to defecate. The authors reported that constipated subjects with rectal hyposensitivity demonstrated higher thresholds for inducing rectoanal reflexes and abnormal characteristics of sensorimotor response. While testing of rectal sensation appears to be a promising research tool, there is a lack of data demonstrating its utility in clinical practice. All told, the requested rectal sensory testing (91120) is not medically necessary for evaluation of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for hormone growth replacement therapy for treatment of the enrollees growth hormone deficiency. Findings:  The physician reviewer found that the request for hormone growth replacement therapy is medically necessary for treatment of the patients medical condition. Nutropin is a recombinant GH which is used as replacement therapy in adult GH deficiency. In this case, the patient had a motor vehicle accident followed by symptoms of frequent headaches, insomnia, short-term memory loss, emotional lability, irritability, light sensitivity, vertigo, fatigue and poor organization skills. Although the patients IGF-1 level was within the normal reference range, the patients glucagon stimulation testing confirmed GH deficiency per Endocrine Society guidelines. 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 internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism 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 parent of an enrollee has requested authorization and coverage for a walker with seat and pelvic support. Findings:  The physician reviewer found that, as is, the goal with all treatment for cerebral palsy, surgery aims to provide children the greatest chance of living as independently as possible. This patient has been in a power wheelchair and his providers report that he is able to ambulate independently within the home and community settings using a walker with seat and pelvic support. He is noted to be using the walker consistently for 45-60 minutes a day and following through on his physical therapy appointments. The patients orthopedic surgeon, pediatrician and physical therapist have reported on the patients ability to use the walker within the home and community, as well as frequency of use with consistent improvement. Studies reported that preoperative functional level can be exceeded and sustained beyond 24 months following surgery. The health benefits of standing and walking as opposed to sitting have been well-documented in the literature. As such, this patient is likely to continue making progress with use of the walker. For these reasons, the requested walker with seat and pelvic support is supported as medically necessary for treatment of this patients cerebral palsy status post lower extremity surgery. Final Result: The reviewer determined that the requested device 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 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 56-year-old male enrollee has requested cervical disc replacement surgery for treatment of his degeneration of cervical intervertebral disc. Findings:  Three physician reviewers found that the request for cervical disc replacement surgery is not likely to be more effective for this patient than other available options. The documentation submitted for review fails to demonstrate that the requested surgery is clinically indicated. The patient presents with several unknown factors, including unknown type of prior cervical spine surgery performed and whether there is either iatrogenic or degenerative fusion of the neck. Further, given the patients multilevel foraminal disease, a posterior approach such as laminectomy and fusion plus or minus foraminotomies is likely more beneficial than the proposed surgery. Based on the information provided for review, the request for cervical disc replacement surgery has not been established in this clinical setting and is not likely to be the more beneficial compared to other modalities.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 52-year-old female status post bilateral below the knee amputations and multi-digit distal phalanx amputations. She is requesting reimbursement for an Electra-Ride III stairlift that was purchased to assist with stair mobility in the home. The Health Plan has denied this request indicating the equipment at issue was not medically necessary for the patients mobility.The Health Plans denial should be upheld. The submitted clinical evidence does not demonstrate the Electro-Ride III stairlift is required for the patient to move between floors in her home. The information provided indicates the patient has the demonstrated ability to ascend and descend three flights of stairs. As such, the equipment at issue was obtained for convenience purposes rather than out of necessity. Therefore, I have determined the equipment at issue was not medically necessary for the patients mobility. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested implantation of intrastromal corneal ring segments (INTACS) for treatment of his medical condition. INTACS offers a safe and effective option for treatment of keratoconus. It avoids the need for penetrating keratoplasty in which the entire thickness of the cornea is removed and replaced with corneal tissue. Penetrating keratoplasty involves a long healing process and may be subject to graft rejection and other issues. As such, the INTACS procedure was a more appropriate option for treatment of the patients keratoconus. All told, the submitted documentation demonstrates the medical necessity of the INTACS surgery.Final Result: The reviewer determined that the procedure at issue was medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The physician reviewer is board certified in ophthalmology 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 retroactive authorization and coverage of digital breast tomosynthesis for evaluation of the enrollees risk for breast cancer. Findings: Three physician reviewers found that Tomosynthesis was approved by the U.S. Food and Drug Administration (FDA) for clinical use. Despite the lack of long-term studies proving an increased survival rate when tomosynthesis has been used as part of screening mammography, the American College of Radiology (ACR) urged the technique be removed from the investigational category due to the advantages this new tomographic technique brings to radiologists interpreting mammograms. This technique often allows radiologists to separate dense glandular elements from underlying masses and architectural distortion resulting in a decrease in callbacks and increased detection of small cancers. Thus, the addition of tomosynthesis to the usual two-dimensional protocol was likely of greater benefit to this patient than had her exam been done with two-dimensional imaging alone. Accordingly, breast Tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: Three 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 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for myPath Melanoma gene expression profile test. Cutaneous melanoma is initially treated by wide surgical excision and sampling of sentinel lymph nodes for those with high depth of invasion, 0.76-1.0 mm. Metastases to regional lymph nodes may be amenable to excision but they suggest a high risk for the development of metastatic disease in the future. There are some lesions that are considered challenging from a histopathological viewpoint. However, there is a lack of data in the peer-reviewed medical literature demonstrating improved patient health outcomes with use of the myPath Melanoma testing for evaluation and treatment planning purposes as compared to standard testing and assessment. The records provided for review document that this patient presented with neoplasm of uncertain behavior of skin. A pathology report demonstrated moderate atypical compound melanocytic nevus, lesional cells involving the peripheral biopsy margin. A sample was submitted for analysis with myPath Melanoma gene expression profile. On review of the current medical literature and guidelines, there is a lack of support for the myPath test for evaluation of this patient. Accordingly, the myPath Melanoma gene expression profile test was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Findings: Two of the three physician reviewers found the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewer 1 is board certified in internal medicine with subspecialty certifications in medical oncology and hematology and is actively practicing. Physician reviewer 2 is board certified in medical oncology with subspecialty certification in hematology and is actively practicing. Physician reviewer 3 is board certified in internal medicine with subspecialty certifications in hematology and medical oncology and is 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 parent of a 4-year-old male has requested 4 hours per week of 1-to-1 speech therapy for treatment of his autism.  Findings:  The physician reviewer found that the standard of care adopted by the medical community as set forth by evidence based guidelines for autism by the American Academy of Neurology (AAN) and Child Neurology Society (CNS) developed in 2000 recommends speech therapy for children with autism. According to these organizations, the treatment of autistic individuals requires a comprehensive multidisciplinary approach inclusive of speech therapy. They indicate that the goal of early identification of speech and language problems is to initiate early intervention, which has been shown to improve outcomes for children who have ASD.   Thus, speech therapy is the standard of care for young patients with autism. In light of this patients documented deficits associated with his diagnosis of autism, 1-to-1 speech therapy at a frequency of 4 hours per week was and is medically necessary. The patient should continue to receive such services for six months from the date of this decision. At the end of the six-month period, the patient should be re-evaluated to determine his progress and the need for additional therapeutic intervention.
Appeal type: Medical Necessity
Decision: Upheld

A 38-year-old female enrollee has requested diagnostic tests  for an evaluation of her multiple symptoms including headache, stomach problems, abdominal cramps, mood changes, fatigue, mental dullness and bloating. Findings:  The physician reviewer found that the submitted clinical information has demonstrated that the studies obtained were not medically necessary. There was no documentation of a physical exam or specific diagnosis or impression that would warrant the medical need for the tests provided. The patient had been thoroughly evaluated by the listed specialty services. Furthermore, there is no standard for evaluation of the accuracy of the tests obtained related to the patients specific medical conditions.