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

The father of a three-year-old female enrollee requested authorization and coverage of applied behavioral analysis therapy. The Health Plan denied the request indicating that the requested therapy is not medically necessary for the treatment of the enrollees autism.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested therapy is not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for eight hours per day of in-home skilled nursing services provided and forward. Findings:  The physician reviewer found that The request for eight hours per day of in-home skilled nursing services provided and  forward is medically necessary for treatment of the patients medical condition. According to the American Academy of Pediatrics (AAP) guidelines for home care of infants, children, and adolescents with chronic disease, comprehensive planning should minimize physical and emotional risk to the patient, adverse effects on family members, or unforeseen financial burdens. AAP guidelines further state that the goal of a home health care program for infants, children, or adolescents with chronic conditions is the provision of comprehensive, cost-effective health care within a nurturing home environment that maximizes the capabilities of the individual and minimizes the effects of the disabilities. Treacher-Collins syndrome, also known as mandibulofacial dysostosis, is an autosomal dominant syndrome characterized by facial abnormalities, including lower eyelid colobomas, sunken cheekbones, blind fistulas at the corners of the mouth and by the ears, deformed external ears, receding chin, large mouth, and abnormal hair growth pattern. Facial clefts and deafness may occur. The mandible and other facial bones may be hypoplastic. Dental abnormalities are common. In infancy, airway and feeding are of greatest concern, requiring tracheostomy and gastrostomy placement. Over time, surgical reconstruction may be performed to approximate normal facial structure. In this case, the patient has a number of medical issues as a result of and in addition to his prematurity and congenital abnormalities. Given the severity of the patients defects and potential for complications with increased morbidity, it is not reasonable or safe for the parents to care for the patient round-the-clock. The patients needs must be addressed 24 hours a day. Skilled nursing provides the level of proficiency needed to maintain the patients health and well-being, preventing morbidity and maximizing development, and allowing the layperson caregivers time to maintain the household, and address personal needs. As such, the request for in-home skilled nursing services is medically necessary eight hours daily from date of denial and forward.  Final Result: The reviewers determined that the requested service is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: Physician reviewer is board certified in pediatrics with sub-specialty certification in pediatric critical care 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

An 18-year-old female enrollee requested authorization and coverage of continued acute mental health inpatient treatment for anorexia nervosa.  The health plan denied the enrollees request indicating that the requested treatment is not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer upheld the health plans denial on the basis that the requested continued acute mental health inpatient treatment is not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for diclofenac sodium 1% gel. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the patients posterior tibial tendinitis with plantar fasciitis secondary to pathomechanics. The submitted documentation supports the medical necessity of the requested medication. The current literature supports the use of topical NSAIDs for musculoskeletal pain. Topical NSAIDs provide significant levels of pain relief in painful musculoskeletal conditions such as plantar fasciitis, as well as traumatic conditions, which can be similar to that provided by oral NSAIDs. Gel formulations of diclofenac, also known as the brand name, (as Emugel), ibuprofen, ketoprofen, and some diclofenac patches, provide the best effects. These treatments are recommended by the U.S. Food and Drug Administration. Adverse events related to their use are usually minimal. It is well documented that the patient is unable to tolerate oral NSAIDs. As such, diclofenac sodium 1% gel is reasonable, appropriate, and 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 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: Overturned

A 43-year-old female enrollee requested Jardiance and Bydureon for medical treatment of the enrollee, who has diabetes.  Findings:  The physician reviewer found that there is sufficient support for Jardiance and Bydureon in this clinical setting.  The medical records document a history of bariatric surgery and poorly controlled diabetes.  This combination of medications has helped the patient to lose weight and achieve improved diabetes control.  The current medical evidence supports the requested medications for the treatment of this patient.  All told, Jardiance and Bydureon are medically indicated in this case.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for edaravone for treatment of the enrollees amyotrophic lateral sclerosis. Findings:  The physician reviewer found that there are conflicting results relative to the effectiveness of edaravone in the treatment of ALS with some studies demonstrating no efficacy. Some of the available studies regarding the use of edaravone suggest some efficacy for those patients with recent diagnosis. The specifics of this case demonstrate that this patient has had slow progression of ALS for over five years. There is a lack of evidence to indicate the superior efficacy of this medication for treatment of patients with ALS. Therefore, edaravone (Radicava) is not likely to be more efficacious than the available options for treatment of this patient.  Final Result: All three reviewers determined that the requested medication is 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 reviewer number one is board certified in 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.Physician reviewer number two is board certified in 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.Physician reviewer number three is board certified in neurology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential treatment center services. Findings:  The physician reviewer found that residential treatment center services provided were not medically necessary for treatment of the patients behavioral health condition. The patient had minimal post-acute withdrawals. He was not a danger to himself or others. He was medically and psychiatrically stable. There were no emotional, behavioral, cognitive, impulsive, psychotic, or manic concerns which would have precluded stepping him down to a lower level of care. He was motivated for treatment. His wife was supportive and his living environment was alcohol free. There was no evidence to suggest that he would deteriorate if treated at a lower level of care. His recovery could have continued at a lower level of care, in conjunction with additional community based Alcoholic Anonymous (AA) meetings, along with help from his sponsor. For the reasons provided, the services at issue were not medically necessary for treatment of the patients medical condition. 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: Physician reviewer number two is board certified in psychiatry with sub-specialty certification in addiction 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

Nature of Statutory Criteria/Case Summary: A 37-year-old female enrollee has requested authorization and coverage for a consultation with a podiatrist. Review of criteria indicates that a referral is medically necessary when the nail requires further testing and that the patient has failed systemic medications. Due to the risks and complications of the systemic medications, the nail condition requires further testing to establish an indication for their use. Since further testing to confirm that antifungal medication has not been performed, the requested podiatry referral is medically necessary for evaluation of this patients medical condition. Final Result: The reviewer determined that the requested services are medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in podiatry 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 authorization and coverage for Harvoni for 12 weeksfor treatment of the enrollees hepatitis C. 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. The guidelines recommend that all patients should be treated, regardless of fibrosis stage. The guidelines recommend that non-cirrhotic, treatment-naive, genotype 1 patients, or those who have failed peg-interferon and ribavirin, should be treated with Harvoni for 12 weeks. These recommendations are based on multiple randomized clinical trials, and the medication is U.S. Food and Drug Administration approved for all patients with chronic hepatitis C, genotype 1 regardless of fibrosis stage. Final Result: The reviewer determined that the requested medication regimen 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 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.
Appeal type: Experimental/Investigational
Decision: Upheld

The parent of a three-year-old male enrollee has requested applied behavioral analysis (ABA) services (25 hours per week of ABA therapy and 6 hours per week of professional progress assessment and evaluation) for treatment of his autism. Findings:  Two physician reviewers found that the use of ABA in autism or in other Pervasive Development Disorders is not standard practice. While some components of the therapy may have utility, the use of ABA for such an extended time period is not supported in the recognized medical literature and is, at this time, investigational. There is no evidence such an approach will be more effective than standard interventions. ABA therapy is considered by many to be an educational intervention.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The enrollee has requested authorization and coverage for a panniculectomy for treatment of the enrollees excess skin in the abdominal area. Findings:  The physician reviewer found that there is sufficient support in the documentation for the requested services in this clinical setting. The photographs show evidence of a significantly abnormal asymmetric lower abdominal pannus as well as significant protuberance on profile view. Additionally, there appears to be an irregular scar deformity of the lower abdomen, as well. The documentation shows a severely abnormal abdomen as the result of previous major intra-abdominal surgery. Common functional problems associated with an overhanging pannus or skin redundancy are disabling rashes, pain, physical limitation, and back strain.  In this patients case, the record supports indications for panniculectomy. Therefore, the requested panniculectomy is medically necessary for the treatment of this patients medical condition.  With regard to whether the requested services are considered reconstructive in nature, in this patients case, the abdomen is significantly abnormal and the abdominal presentation is likely the direct result of the patients previous intra-abdominal infection due to an intestinal perforation.  As such, the aim of the surgery is to create a more normal appearance and based on review of the photographs, a more than a minimal improvement would be likely. Final Result: The reviewer determined that the overturned the Health Plans denial on the basis that the requested services are medically necessary and are reconstructive in nature. Credentials/Qualifications: The reviewer is board certified in plastic 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

A 37-year-old male enrollee has requested for the Fluency Master for treatment of his speech pathology. Findings:  Three physician reviewers found that the Fluency Master is an electronic device that uses a technology called altered auditory feedback (AAF). According to the manufacturer, the device fosters better hearing of the natural vocal tone associated with speaking. In 2002, the National Stuttering Association conducted a survey of its membership. One of the questions asked was about experiences with an AAF device, including the Fluency Master. 38% of the respondents categorized  their experience with this type of device as not at all successful, 44% said their experience was somewhat successful, and 18% reported their experience was very successful. Bothe, et al. conducted a systematic review of the evidence for behavioral, cognitive, and related treatments for stuttering and concluded that research utilizing a rigorous experimental design was lacking. Although the Fluency Master may be helpful in some circumstances, there are no long-term, randomized, controlled studies demonstrating efficacy.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 35-year-old female teacher who is exposed to children from the Far East where hepatitis B is quite prevalent. She has requested authorization and coverage for a hepatitis B vaccination. The Health Plan has denied the patients request on the basis that the requested vaccination is not medically necessary.The Health Plans denial should be overturned. Hepatitis B vaccination is medically necessary for this patient. Although she is not at high-risk for being infected with hepatitis B, her job as a teacher requires her to be around children who may be carriers of the disease and there is a risk of exposure to the disease. As such, hepatitis B vaccine is reasonable and appropriate for this patient. Therefore, I have determined that the requested vaccination is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for platelet-rich plasma injection to the right elbow. Platelet-rich plasma injection therapy is a technique using a concentrated portion of autologous blood in an attempt to augment and accelerate healing of various tissues. Review studies and national guidelines have not reported substantial improvement in patient health outcomes with use of platelet-rich plasma for the treatment of musculoskeletal disorders. Currently, data suggest that the use of platelet-rich plasma for most musculoskeletal soft tissue injuries should occur within the context of a well-designed clinical trial. There is a paucity of studies demonstrating the safety and efficacy of platelet-rich plasma for the treatment of chronic pain. There are studies supporting the utility of platelet-rich plasma injections as second-line treatment of lateral epicondylitis. This patient has a history of chronic right elbow pain and a 20-year history of chronic widespread musculoskeletal pain. She has failed treatment with surgery, physical therapy, acupuncture, and corticosteroids. On review, the medical records do not support a diagnosis for her right elbow pain, nor are there imaging study reports of the right elbow demonstrating an objective pathology that might benefit from a platelet-rich plasma injection. Therefore, the requested platelet-rich plasma injection to the right elbow is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Findings:  Two of the three physician reviewers found the requested platelet-rich plasma injection to the right elbow is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested services are 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 orthopedic 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

The patient is a 49-year-old female postoperative from repair of a rotator cuff in March 2003 that resulted in an unfavorable scar (staged to be keloid). This was initially treated with steroid injections with persistent unfavorable result. The patient was then seen by a plastic surgeon who evaluated the scar and proposed excision/revision of the scar. The Health Plan has denied authorization and coverage for the requested procedure on the basis that it is not medically necessary.The records from the patients plastic surgeon do not describe any functional limitation related to the scar. The patients complaints were related to appearance and pain. No plan of pain modification was proposed. Thus, there is insufficient evidence that the requested procedure is medically warranted. Furthermore, the requested scar revision would have serious limitations as keloid removal by any method has a significant chance of recurrence. Therefore, I have determined that the requested procedure is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

A 47-year-old female has requested gastric bypass surgery for treatment of her obesity.  Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of gastric bypass surgery in this case. The patient does not meet the National Institutes of Health (NIH) criteria for weight loss surgery. Bariatric surgery is indicated for patients with a BMI of 40, or a BMI of at least 35 with severe co-morbid conditions. Given the patients BMI of 31, she does not meet the standard definition of clinically severe obesity at this time. The risks of weight loss surgery outweigh the benefits in this patient population. Additionally, multidisciplinary clearance has not been obtained and there are pending behavioral compliance requests that have not been completed.
Appeal type: Medical Necessity
Decision: Upheld

A 53-year-old enrollee requested authorization and coverage of a referral to an out-of-network sleep disorders clinic for the treatment of sleep difficulties.  The Health Plan denied the enrollees request indicating that the requested treatment is not medically necessary.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 for treatment of the patients medical condition.