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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Cialis 5 mg daily, #30 per 30 days for treatment of the enrollee, who has been diagnosed with benign prostatic hyperplasia and erectile dysfunction. Findings:  The physician reviewer found that Phosphodiesterase-5 (PDE-5) inhibitors like Cialis have been studied in men with benign prostatic hyperplasia/lower urinary tract symptoms.  The efficacy of Cialis for benign prostatic hyperplasia/lower urinary tract symptoms is based on findings that show the expression of the PDE-5 enzyme in the lower urinary tract (prostate, bladder, urethra and vascularity).  PDE-5 inhibition results in smooth muscle relaxation and may increase pelvic blood perfusion, which is suspected to affect smooth muscle tone.  Clinical studies have demonstrated that Cialis 5 mg once daily leads to statistically significant improvements in International Prostate Symptom Score (IPSS) as early as one to two weeks after beginning therapy.  The standard of care for treatment of patients with benign prostatic hyperplasia includes alpha blockers and 5 alpha reductase inhibitors.  Studies comparing alpha blockers and daily Cialis used a monotherapy have failed to prove superiority of daily Cialis over alpha blocker therapy.  Hence, the use of Cialis for treatment of benign prostatic hypertrophy is not medically necessary.  Cialis 5 mg once daily is an option for treatment of men with erectile dysfunction.  However, the current medical literature does not support improved efficacy with use of daily Cialis in patients who are responding adequately to as needed Cialis therapy.  In addition, the current medical literature does not support improved efficacy of Cialis over equivalent dose of sildenafil (Viagra).  Hence, the use of Cialis for treatment of erectile dysfunction is not medically necessary.  All told, Cialis 5 mg daily, #30 per 30 days is not medically indicated for the treatment of this patient. Final Result: The reviewer determined that the requested medication regimen is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The physician 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: 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 condition. Findings:  The physician reviewer found that based on the Level of Care Utilization System (LOCUS) criteria, the patient met criteria for treatment in a less restrictive environment. The patients risk of harm score is two (2), mild risk of harm. The patient did not have any suicidal ideation or homicidal ideation. The patient has no history of any suicide attempts. The patients functional status score is two (2), mild impairment. The patient has a successful job that he has been able to keep. He reported that he did not drink on the job. He reports that he is not concerned about any family issues. He has good relationships with Alcoholics Anonymous (AA) friends and work friends. The patient broke up with his significant other after relapsing on alcohol. The patient has no legal problems. The patients medical, addictive, psychiatric co-morbidity score is three (3), significant co-morbidity. The patient has a significant co-morbidity of alcohol use disorder, depression, and anxiety. He has no medical problems which require 24-hour monitoring. The patients recovery environment score is two (2), mildly stressful environment. The patient is single. He recently broke up with his significant other due to his drinking. The patients level of support score is two (2), supportive environment. The patient has supportive contacts including AA friends. The patients treatment history score is two (2), significant response to treatment and recovery. The patient has had prior sobriety. The patients engagement and recovery status score is two (2), positive engagement and recovery. The patient is motivated for recovery and is compliant with treatment recommendations. Based on these criteria, the patient has a total score of 15 and would meet criteria for outpatient treatment along with AA treatment.  Final Result: The reviewer determined that the residential treatment 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: Overturned

This patient is a five-year-old male with a diagnosis of periventricular leukomalacia and apraxia of speech as well as dysarthria, developmental motor coordination disorder and apraxia of movements.  I have reviewed both the medical reports and speech therapy reports included in the record.  The patient has been receiving speech therapy since September 2004.  His parents have requested reimbursement for speech therapy provided from May 2005 through October 2005 and continuing authorization of speech therapy. The Plan has denied their requests based upon a determination that the therapy was/is not medically necessary.In my review of the therapy reports I found that the therapists presented objective and subjective data regarding receptive and expressive language.  A therapist in Wisconsin performed the initial objective testing when the patient was four years and seven months old.  This placed him at the first percentile for receptive language skills with an age equivalence of three years and zero months.  Subsequent testing showed an increase to the third percentile.  It is difficult to determine if this was a true increase or if it reflected a difference in his mood on a given day.  However, subsequent testing showed mild but continued progress in both auditory and expressive comprehension.  Additionally, the expressive vocabulary documented in the subjective measures of the March 2006 progress report clearly demonstrates a large increase in verbal expression as compared to previous evaluations.  The patient has a documented brain abnormality consistent with his speech and language deficits. His treatment plan is well established and it is monitored by a physician experienced in the evaluation and treatment of his condition. Therefore, I have determined the therapy at issue was/is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.  Objective testing should continue every six months and be reviewed by the pediatric neurologist.  Speech therapy services should continue as long as objective testing demonstrates continued functional gain.
Appeal type: Experimental/Investigational
Decision: Overturned

A 56-year-old female enrollee has requested NeuroStar transcranial magnetic stimulation (TMS) with weekly maintenance therapy for up to one year for treatment of her major depression.  Findings:  Two physician reviewers found that this patient presents with a long history of major depressive disorder which has been refractory to numerous medication trials, psychotherapy, and ECT. In addition, she has a history of suicidality requiring hospitalization. She was treated with TMS by her treating psychiatrist with documented reduction in symptoms. TMS has been approved by the Food and Drug Administration (FDA) since 2008. Moreover, there are adequate studies showing the benefit of TMS with minimal, if any, negative side effects. This patient has shown an improvement with the NeuroStar TMS therapy for her sustained depression despite a lack of improvement with other therapies. Therefore, it is reasonable that this patient continue this technique which has been shown to improve patients with this disorder.
Appeal type: Medical Necessity
Decision: Overturned

A 51-year-old female enrollee has requested Zomig 5mg at a quantity of 18 tablets per month for treatment of her migraine headaches.   Findings:  The physician reviewer found that the requested Zomig 5mg at a quantity of 18 tablets per month is a high amount of triptans per month. The patient has a history of migraine headache and reports using triptans for over four years. The patient likely has medication overuse headache and there is data in the medical literature to suggest that use of 12 or more triptans per month may cause medication overuse headache. This patient reports she is missing work due to her frequent migraine. It is typical that patients who are overusing triptans have headache when they are not using the triptans frequently, and that they respond well to reintroduction of the triptan. Further, the patient is not on any type of preventive therapy. The use of preventive therapy is standard of care in patients with high frequency migraine, especially if there is any significant disability. Twelve triptans per month is a reasonable amount for patients with high frequency episodic migraine or chronic migraine, but 18 per month is a higher amount than is generally accepted by headache specialists. Therefore, Zomig 5mg at a quantity of 12 tablets per month is a reasonable amount and medically necessary for treatment in this patients case and a cohesive plan should be implemented for preventive therapies such as beta blockers, topiramate, amitriptyline, or Botox. Based upon the documentation submitted for review and the peer-reviewed literature, the medical necessity of Zomig 5mg at a quantity of 12 tablets per month is reasonable and appropriate in this clinical setting.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested breast tomosynthesis for evaluation of her medical condition. Findings: Three physician reviewers found that breast tomosynthesis provides advantages in this clinical setting.  In cases of extremely dense or heterogeneously dense tissue, the technique often enables the provider to separate dense glandular elements from underlying architectural distortion/mass thereby resulting in a decrease in callbacks and increase in detection of small cancers.  Thus, the addition of tomosynthesis to the usual two-dimensional protocol was likely of more benefit to the patient than had the examination been done with the two-dimensional technique alone.  In sum, breast tomosynthesis performed was likely to have been of greater benefit than other modalities.  Final Result: Three 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. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: All three physician reviewers are board certified in diagnostic radiology 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: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for general anesthesia services. The American Dental Association (ADA) recommends moderate sedation for patients with American Society of Anesthesiologists (ASA) score of III or IV, and obesity, especially when associated with airway associated morbidity. The ADA also reports that deep sedation or general anesthesia may be appropriate 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 (Cote, et al.). The records provided for review document that this patient required a surgical tooth extraction and she experienced substantial anxiety related to the procedure. The provider stated that the patient was had difficulty with anesthetizing in preparation for a simple procedure. The patient indicated that her provider recommended general anesthesia for the extraction. However, there is a lack of documentation that this patient has an anesthesia classification score ASA of 3 or 4, or evidence of a difficult airway. The anesthesia record from 4/29/21 shows that the patient was given an ASA classification of 2. The diagnosis of attention deficit disorder (ADD) is not considered a developmental disability that prevents a patient from undergoing a tooth extraction without sedation or general anesthesia. Moreover, the patients preoperative blood pressure was charted as 148/89, which does not constitute a hypertensive urgency or emergency. The providers records do not include sufficient documentation to support an indication for general anesthesia for the tooth extraction. Therefore, the general anesthesia services were not medically necessary for 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 anesthesiology with subspecialty certification in pain medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 16-year-old female enrollee has requested an external infusion insulin pump (Medtronic Revel for treatment of the enrollees type 1 diabetes. Findings:  The physician reviewer found that this patient has a history of widely fluctuating blood glucose levels before meals.  Transition to insulin pump therapy will likely improve this patients daily management of her diabetes, improve glycemic control, and lower the risk of hypoglycemia and diabetic ketoacidosis. Several studies published in peer-reviewed journals have shown that insulin pump therapy is safe and effective in children and adolescents with type 1 diabetes.  Compared with conventional insulin treatment, continuous subcutaneous insulin infusion improves glycemic control, limits excessive weight gain, reduces the frequency of hypoglycemic events, and results in overall improved satisfaction in patients and their parents.  This patient and her family have adhered to frequent blood glucose monitoring, have kept appointments with the patients various health care providers, and have attempted to comply with dietary recommendations.  Thus, they have demonstrated that they possess the necessary tools to carry out an effective treatment and follow-up plan on insulin pump therapy. In this patients case, the requested external infusion insulin pump is medically indicated.
Appeal type: Experimental/Investigational
Decision: Overturned

A 54-year-old female enrollee has requested an Oncotype DX tumor assayfor evaluation of her breast cancer.  Three physician reviewers found that Oncotype DX assay predicts quite accurately the risk of distant recurrence of the cancer by 10 years if the patient is treated with hormonal therapy as the sole systemic treatment. There is good literature support for its reliability. The assay has been shown to be valid only in node-negative, estrogen receptor-positive tumors. It has become very important, particularly in cases in which it is very difficult to make recommendations about adding adjuvant chemotherapy. Indeed, many oncologists have adopted it as part of their standard evaluation of such patients. Additionally, Medicare has approved the use of the Oncotype DX assay.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a nine-year-old female with a diagnosis of dento-facial dysfunction and developmental articulation delay for which she has received speech therapy. No specific medical report addresses the extent of the developmental delays. The therapist reports a Photo Articulation Test resulted in a standard score of 95 and an age equivalency of 8 years 3 months. In addition, a lingual neutral position accuracy of 90% was noted. At issue is whether speech therapy was medically necessary for this patient.Review of the scientific literature regarding myofunctional therapy does not reveal sufficient evidence of its efficacy. Although the program is sanctioned by the American Speech-Language Hearing Association, they acknowledge that the research evaluating its efficacy is limited, of a small scale, and uncontrolled. Most of the studies document some benefit in treating tongue thrust, but do not show significant evidence of improvement in articulation.In reviewing the medical reports as well as the daily progress notes there is no objective standardized or non-standardized data showing improvement in the patients condition or that the patient has a clinically significant delay in speech articulation or expressive/receptive language disorder. Furthermore, no medical illness or injury is documented in the records provided. As such, there is insufficient evidence speech therapy was medically warranted in this case.For the reasons set forth above, I have determined the therapy at issue was not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Overturned

SummaryThe patient is a 29-year-old female with long-standing diabetes complicated by severe gastroparesis.  Her provider has recommended gastric electrical stimulation.  The Health Plan has denied coverage for the requested procedure on the basis that it is considered investigational.  All three of the physician reviewers concluded that the Health Plan denial should be overturned.  Analysis and FindingsClinical Facts:  The patient has a history of severe diabetic gastroparesis refractory to medical management. She is currently on total parenteral nutrition (TPN). She suffers from constant nausea and recurrent episodes of vomiting requiring Zofran every six hours. She has sought treatment at the emergency room almost on a weekly basis and has required frequent hospitalization. A gastric emptying study was markedly abnormal with 20% gastric emptying at 30 minutes and 14% gastric emptying at 120 minutes.  The patient has filled multiple anti-emetics and requires continuous use of narcotic analgesics and benodiazepines. She has also used Zofran and a TCA antidepressant. An endoscopy performed in February 2006 was normal. A gastric emptying study performed in May 2006 confirmed severe gastroparesis.Reviewers Findings: The three reviewers found that the patient meets entry criteria as outlined by the manufacturer for use of the gastric electrical stimulator. These include symptomatic gastroparesis for greater than one year, refractory or intolerant to at least two anti-emetic and prokinetic drug classes, frequency of vomiting greater than seven times per week, and delayed gastric emptying defined by greater than 60% retention at 2 hours and greater than 10% retention at 4 hours.  Also, all conservative medical therapy to this point has failed.  Therefore the three reviewers found that the Health Plan denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for hyperbaric oxygen treatment. The records provided for review report a history of anal fissure, skin tags, and hemorrhoids. The provider noted that the patient underwent skin tag removal in August 2021 and January 2022. The patients provider has recommended further treatment with hyperbaric oxygen therapy. There are adequate studies to support hyperbaric oxygen therapy for the treatment of patients with anal fissures and Crohns or ulcerative colitis that have failed conservative treatment (Lansdorp, et al.). Numerous studies also support hyperbaric oxygen therapy for the treatment of patients with radiation related rectal disease (Andren and Bennett). However, this patients records do not document a history of inflammatory bowel disease or treatment with radiation therapy. There is a paucity of support in the peer-reviewed medical literature for the utility of hyperbaric oxygen therapy in the treatment of this patients anal fissure. Therefore, the requested hyperbaric oxygen treatment 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. Credentials/Qualifications: The reviewer is board certified in family medicine with subspecialty certifications in preventive medicine, and undersea and hyperbaric medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 38-year-old male enrollee requested authorization and coverage of a laminectomy and fusion. The Health Plan denied the request indicating that the requested procedures are not medically necessary for the treatment of the enrollees herniated disc.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested procedures are not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

A 45-year-old female enrollee requested authorization and coverage of a power-operated vehicle (POV). The Health Plan denied the request indicating that the requested equipment is not medically necessary to assist with the enrollees mobility.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested equipment is not medically necessary.