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

A 61-year-old female enrollee has requested upper eyelid blepharoplasty for treatment of her chronic dermatitis and dermatochalasis. Findings:  The physician reviewer found that while the submitted evidence shows only minimal changes in the patients field of vision secondary to ptosis, the patient also presents with chronic dermatitis and dermatochalasis which have not responded to conservative therapy. According to guidelines set forth by the American Academy of Ophthalmology, chronic eyelid dermatitis is an indication for upper eyelid blepharoplasty when the dermatitis persists despite maximal medical therapy. This patient has chronic upper eyelid dermatitis and has been maintained on steroidal and non-steroidal medications without improvement. Continuation of medical management is not likely to be successful. The patient has a functional impairment secondary to eyelid dermatitis and dermatochalasis which requires treatment with upper eyelid blepharoplasty.
Appeal type: Medical Necessity
Decision: Overturned

A 54-year-old female enrollee requested authorization and coverage of gastric bypass surgery. The Health Plan denied the enrollee's request indicating that the requested procedure is not medically necessary for the treatment of the enrollees obesity.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plans denial on the basis that the requested procedure is medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for phenazopyridine 200 mg. The Health Plan has denied the request and reported the requested medication is not medically necessary for the treatment of this patient. The Health Plan offered phenazopyridine 95 mg or 97.5 mg as an alternative. At issue in this case is whether phenazopyridine 200 mg is medically necessary for the treatment of the patients medical condition. The American Urological Association reports that in UTI, acute-onset symptoms attributable to the urinary tract typically include dysuria in conjunction with variable degrees of increased urinary urgency and frequency, hematuria, and new or worsening incontinence. Shore and colleagues reported that phenazopyridine is a urinary tract analgesic indicated for short-term treatment of irritation in the lower urinary tract. Despite the lack of evidence for extended use, it is often used in varying durations for supportive care for cancer patients with radiation-induced cystitis. Shore and colleagues also noted that phenazopyridine was most commonly prescribed as 100-200 mg three times daily and the study results showed that in doses as high as 200 mg, there were no significant safety issues with uses longer than 14 days. Phenazopyridine 200 mg three times daily is a common dosage used in interstitial cystitis. Lower doses may be appropriate in primarily infectious cystitis. In this case, the patients chronic dysuria is consistent with radiation cystitis. The medical evidence supports the requested medication dosage in this clinical setting. Therefore, phenazopyridine 200 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 urology 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 50-year-old female enrollee has requested past and future coverage for hormone replacement pellet therapy for treatment of her menopause-related vasomotor symptoms.  Findings:  Three physician reviewers found that during the transition from the reproductive years through menopause and beyond, a woman experiences many physical changes.  Most of these changes are normal consequences of both menopause and aging.  All women experience menopause, but each in a unique way.  Although for many women menopause is asymptomatic and associated with little disruption of normal life and well-being, many women experience symptoms that considerably impact their quality of life.  Several prescription drugs are available to help relieve menopause-related symptoms. Hormone therapy is the most effective intervention for management of these quality-of-life issues. Over the years, a number of research studies presented a complicated picture of the risks and benefits of hormone therapy, and its use for prevention of cardiovascular diseases was controversial. This led the National Institutes of Health (NIH) to conduct a large clinical trial of the risks and benefits of hormone therapy.  Results from the trial published in 2002 showed that the overall risks of estrogen plus progestin outweigh the benefits.  Compounded bioidentical hormones are plant-derived hormones that are prepared, mixed, assembled, packaged, and labeled as a drug by a pharmacist. These preparations can be custom made for patients according to a physician's specifications. Bioidentical hormones refer to hormones that are biochemically similar or identical to those produced by the ovaries or body.  According to a Committee Opinion released by the American Congress of Obstetricians and Gynecologists, there is a lack of scientific evidence to support claims of increased efficacy or safety for individualized estrogen or progesterone regimens prepared by compounding pharmacies.  There is no evidence that bioidentical hormones have any advantage over conventional hormone therapies. Of note, the quality of compounded products may be substandard in some cases.  According to the American Congress of Obstetricians and Gynecologists, most compounded products, including bioidentical hormones, have not undergone rigorous clinical testing for either safety or efficacy. Also, there are concerns regarding the purity, potency, and quality of compounded products.  All told, hormone replacement pellet therapy was not and is not likely to be more efficacious than other available treatment options in this patients case.
Appeal type: Experimental/Investigational
Decision: Upheld

A 60-year-old male enrollee has requested Supartz injections for the treatment of his arthritis. Findings:  Two physician reviewers found that at this time, Supartz is only FDA approved for use in the knee. Other joints, including the shoulder, have been tried with limited success. There is no evidence in the peer reviewed scientific literature that supports the use of viscosupplementation in the shoulder. Thus, Supartz injections are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Experimental/Investigational
Decision: Upheld

A 43-year-old male enrollee has requested intradiscal electrothermal annuloplasty procedure for treatment of his back pain. Findings:  Two physician reviewers found that intradiscal electrothermal annuloplasty was not likely to be more beneficial than other treatment options in this patients case.  There is a paucity of peer-reviewed medical literature to support the efficacy of the procedure at issue in reducing pain and improving functionality in patients with chronic discogenic low back pain.  Davis and colleagues performed a retrospective study with independent evaluation of patient outcomes approximately one year post-intradiscal electrothermal therapy. The goal was to assess the functional status, symptoms and subsequent treatments of patients treated with intradiscal electrothermal therapy. They found that several studies reported improvement in greater than 70% of patients. However, at one year post-procedure, half of these patients were dissatisfied with their outcome. The percentage of patients on disability remained constant. The estimated proportion of patients undergoing fusion was predicted 15% at one year and 30% at two years. Freeman performed a systematic review of published, randomized, controlled trials and prospective studies to assess the current evidence of clinical efficacy for intradiscal electrothermal therapy. On average, Freeman found that evidence for efficacy of this procedure remains weak and has not passed the standard of scientific proof. Overall, the intradiscal electrothermal annuloplasty procedure performed was not likely to have been more effective than other available treatment modalities.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:   An enrollee has requested magnetic resonance imaging (MRI) of the back and neck spine without dye for evaluation of her neck and back pain with decreased range of motion and radiation of pain to the right leg. The physician reviewer found that based on the available documentation, an MRI of the lumbar spine without dye is medically necessary for further evaluation of this patients complaints. This patient continues with the same symptoms referable to her low back at which time a positive EMG revealed possible lumbar spine compromise. MRI was recommended at that time and not done. Thus, this exam is considered medically necessary. However, neurological exam does not document cervical radicular signs or symptoms to support an MRI of the cervical spine. Moreover, the presence of pain and decreased range of motion are not indications for MRI of the cervical and thoracic spine under the National Imaging Associates (NIA) clinical guidelines. Thus, an MRI of the lumbar spine without dye is medically necessary, while an MRI of the cervical and thoracic spine is not medically necessary for evaluation of this patients medical condition. Final Result: The reviewer determined that a portion of the requested services is 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 diagnostic radiology 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 enrollee is requesting reimbursement for a continuous positive airway pressure (CPAP) machine. The enrollee has a history of loud snoring and an Epworth Sleepiness Scale greater than nine, for which consultation with a sleep specialist is suggested. The provider diagnosed the enrollee with severe obstructive sleep apnea (OSA). He ordered a continuous positive airway pressure (CPAP) machine and mask with in-line humidity. The literature indicates OSA as a chronic disease; requiring long-term, interdisciplinary management. Options for treating OSA can be medical, surgical or behavioral, but the standard of care and treatment of choice remains the use of CPAP. This treatment is applicable for mild, moderate or severe OSA. This treatment has long been considered the standard of practice. Literature notes it remains so. The testing performed on the enrollee demonstrates he falls within acceptable clinical guidelines for this treatment; his continued adherence to program parameters provides support for its continued use. Medical records show a three-month compliance rate of 70%. The care provided to this enrollee was consistent with current practice guidelines and standards of care.Final Result: The reviewer determined that the requested service is medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in sleep 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 63-year-old male with metastatic prostate adenocarcinoma who has been under the care of a medical oncologist for the last four years. He has received appropriate medical treatment, which has included an LHRH blocker, Zoladex, an anti-androgen, Casodex, Zometa, and other chemotherapeutic agents including Taxotere. Despite aggressive treatment, the patients condition is worsening with more bone pain and a rising PSA (140 in August 2004). The patients oncologist wants to add Thalomid to the patients current treatment regimen. The Food and Drug Administration has not approved Thalomid for use in prostate adenocarcinoma. The Health Plan has denied coverage for Thalomid.The patients condition is deteriorating despite utilization of appropriate and aggressive medications. The use of Thalomid in the treatment of prostate adenocarcinoma is not uncommon. In addition, there is evidence indicating Thalomid is an appropriate treatment option for this patient  particularly based upon his deteriorating condition despite appropriate therapy. Therefore, although off-label, I have determined Thalomid is appropriate and medically necessary for this patient. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential treatment center services for treatment of the enrollees behavioral health conditions. Findings:  The physician reviewer found that the physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue. Based on the diagnoses listed by the treatment facility, the patient more than likely needed comprehensive specialty care for her substance use. However, there was no report of the illness burden, health impacts, psychosocial sequelae or patterns of drug use that prompted the admission. Further, there was no mention of psychiatric comorbidity.  Finally, there was no evidence that the patient had failed a less restrictive setting during the episode of illness or that community-based treatment would have been unsafe or inadequate at the time.  A validated rating scale for alcohol withdrawal suggested that medication was not necessary. The patients vital signs were within normal limits, and she denied any pain. As such, the patient was not enduring complicated withdrawal syndrome. The documentation provided did not include a treatment plan, psychosocial assessment, psychiatric evaluation, interpretive summary or a clinical rationale supporting the need for residential placement as opposed to treatment at a lower level of care. Considering the clinical presentation and patient history, residential treatment center services were not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the services at issue were 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: An enrollee has requested authorization and coverage for surgery to remove an adenosarcoma tumor for treatment of her metastatic cancer. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services. Given the extent of the disease in the pelvis and involvement of ureters and small bowel, the tumor is likely unrespectable. It is unlikely that any component of the operation would successfully palliate her symptoms of ureter and bowel obstruction. Given her poor functional status, she would have a very high risk of operative morbidity, such that even if the operation accomplished some goal of palliation, she would be unlikely to achieve an overall improvement in her quality of life.  Final Result: The reviewers 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 surgery with sub-specialty certification in complex general surgical oncology 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 63-year-old female enrollee has requested for continuous monitoring system supplies for treatment of her diabetes.   Findings:  Two physician reviewers found that there is evidence in the literature about the benefits of CGMS in adults and children and the device is accepted in the medical community that specializes in the management of diabetes. This years American Diabetes Associations 2008 Standards of Medical Care in Diabetes states that continuous glucose monitoring may be a supplemental tool to SMBG for selected patients with type 1 diabetes, especially those with hypoglycemia unawareness.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement and prospective authorization and coverage for 20 hours per week of direct applied behavioral analysis (ABA) therapy, 13 hours per month of supervision and four hours per month of parent training provided from the date of service in question, forward. Findings:  The physician reviewer found that there is sufficient support in the peer-reviewed literature demonstrating the correlation between treatment outcomes and treatment intensity for children with autism. In this case, the Health Plan has authorized ABA services for 64 hours per month (approximately 16 hours per week of direct therapy), which is less than what has been provided in the past. Several studies recommend 25 or more hours of weekly ABA to ensure optimal outcomes. Although the patient has made progress in many areas over the last several years, he continues to demonstrate impairment in several areas including social, cognitive, adaptive and executive functions. He requires substantial support in the areas of non-compliance, along with stereotypic behavior and vocal stereotypy. Based on the support in the peer-reviewed literature and clinical documentation submitted, the request for 20 hours per week of direct ABA therapy, 13 hours per month of supervision and four hours per month of parent training provided from the date of service in question, forward was and is medically necessary for treatment of the patients autism. Final Result: The reviewer determined that services at issue were and are 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 pediatrics with sub-specialty certification in developmental-behavioral 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

The parent of a four-year-old male enrollee has requested for continued speech therapy for treatment of the enrollees speech delay.  Findings:  The physician reviewer found that in child development, delay in acquisition of speech is an important predictor for later problems. Research over the past 50 years has yielded several promising approaches and many specific intervention techniques designed to enhance the communication and language development of young children with intellectual and developmental delays and disabilities. In the clinical literature, Gallagher and Chiat found that, Studies of children with language impairment have reported emotional and behavioral problems in 50-75% of that population. In addition, various authors describe children with delayed speech development as being at high risk for other cognitive, social-emotional, and school-related problems. As such, language development is one of the most significant processes of early childhood development. With regard to diagnosis, language disorders are identified when a patient has difficulty with expressive language, receptive language, or pragmatic language. Speech disorders are identified when a patients voice, fluency, or articulation call attention to the speaker because his or her speech is sufficiently different from the norm. Speech and language development should be consistent with a patients overall development and can be tracked using typical milestone markers. As speech therapy is recommended for young patients with speech delay, the primary goal of treatment is to give the patient a reliable way to exchange ideas and information in his or her daily social and educational environment. Treatment is tailored to the specific communication needs of each patient, which vary with disorder type and severity, age, and the etiology of the condition. Speech therapy is the standard of care for patients with speech delay.