Persius/imr-appeals huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a functional electrical stimulation cycle ergometer (FES-CE) for treatment of the enrollees spinal cord injury.Findings:  The physician reviewer found that there is a lack of peer-reviewed literature demonstrating significant health or functional benefit of exogenous neurostimulation therapy of paralyzed muscles using FES cycle.  There have been a number of case reports and small series published over the years providing some preliminary data suggesting possible benefits, but larger studies designed to evaluate the actual clinical efficacy of passive exercise such as FES in the setting of spinal cord injury are lacking. While repeated bouts of exogenous neurostimulation of paralyzed muscle may potentially retard or reverse muscle atrophy in paralyzed muscle, there is no significant health or functional benefit of this achievement in spinal cord injury because the muscle tissue that is gained or spared does not protect against pressure ulcers or provide any other clinically or functionally relevant benefit.  It does not obviate the need for pressure relief. For the reasons provided, the requested FES is an exercise device that provides passive exercise, not active exercise and it is not an appropriate substitute for active exercise using any residual musculature that is still under volitional control. Final Result: Two reviewers determined that the requested equipment 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: Two physician reviewers are board certified in physical medicine and rehabilitation and are actively practicing. One physician reviewer is board certified in physical medicine and rehabilitation with sub-specialty certification in spinal cord injury and is 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: An enrollee has requested authorization and coverage for transcranial magnetic stimulation (TMS) for treatment of the enrollees major depressive disorder, recurrent, severe without psychotic features.Findings:  The physician reviewer found that as noted in the medical literature, TMS is approved by the U.S. Food and Drug Administration (FDA) for patients with major depressive disorder when medications are ineffective. However, from the given documentation, the provider reports that the patient responded well to Nardyl without side effects. In the documentation, it was the patients preference not to take medication for major depressive disorder. As at least one medication was effective for this patient without side effects, the patients condition has not been refractory to medical therapy. Final Result: The reviewer determined that the requested service is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a lightweight folding power operated vehicle (POV)/scooter for treatment of the enrollees Kennedys disease. Findings:  The physician reviewer found that the request for a lightweight folding POV is medically necessary for treatment of the patients medical condition. The benefits of power-mobility devices are reported to include improved quality of life, an increased sense of freedom and improved self-esteem. Patients exhibited high use and satisfaction with their power wheelchairs. In this case, the patient presents with declining functional mobility with frequent falls. The requested device is appropriate for treatment the patients motor neuron disease with progressive weakness and loss of balance. All told, the request for a lightweight folding POV/scooter is medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the requested equipment is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in physical medicine and rehabilitation with sub-specialty certification in neuromuscular 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 39-year-old female enrollee has requested for an MRI of the chest for evaluation of her chest pain.  Findings:  The physician reviewer found that an MRI of the chest is not clinically indicated for the evaluation of this patient. According to the American College of Radiology, a chest MRI is indicated to assess abnormal growths which cannot be assessed adequately with other imaging modalities or which are particularly well-suited to MRI imaging and to determine tumor size, extent and the degree to which the cancer has spread to adjacent structures. Additional indications include assessment of the anatomy and functionality of the heart and its component structures, determination of blood flow dynamics in the vessels and heart chambers, displaying lymph nodes and blood vessels and assessment of disorders of the chest bones and chest wall soft tissue. In this patients case, the medical records do not demonstrate that the patient meets any of these indications for an MRI.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Euflexxa injection series in the right knee.An exhaustive review of the current medical literature pertaining to viscosupplementation reveals mixed results. Evidence from eight systematic reviews and six randomized controlled trials indicates that although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. Different studies have tried mixing hyaluronic acid with corticosteroids, platelet rich plasma, and other agents to make it more effective. The current evidence is limited, and guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate that the evidence is not conclusive. In light of the foregoing, viscosupplementation can only be recommended in individuals with a history of lasting benefit from prior injections, and in carefully selected cases where everything else has been tried, and the options are limited. In this case, the options are limited. The patient has failed other conservative treatment, including a corticosteroid injection. Therefore, the requested Euflexxa injection series in the right knee is medically necessary for the treatment of the patients medical condition.Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 20-year-old female enrollee has requested for a consultation with a neurologist for treatment of her condition. Findings:  The physician reviewer found that a trial of preventive therapy with agents such as topiramate or amitriptyline appears indicated. The trial should start at a low dose, increasing to therapeutic range, and be maintained for at least one month, if tolerable. If there are abnormalities on the exam or other alarming features to the history, or lack of benefit from a prevention regime, neurology consultation should be pursued.
Appeal type: Medical Necessity
Decision: Upheld

A 48-year-old male enrollee requested authorization and coverage of Pegasys and Copegus. The Health Plan denied the request indicating that the requested therapy is not medically necessary for treatment of the enrollees hepatitis C.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

Fifty-four year-old male has been diagnosed with lumbar degenerative disc disease. He continues to have pain with activity.  He is requesting an MRI for further evaluation.Reviewers Findings:The reviewer found that based upon the clinical presentation and his examination of the patient, the patients provider has determined an MRI is indicated to further investigate the cause of the patients pain and to better plan his treatment. As the patient has persistent pain, an MRI study is medically prudent and clinically indicated for further workup as to the cause of his pain.  Therefore, the Health Plan denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested gene testing for evaluation of her medical condition.  Findings:  Two physician reviewers found that metastatic triple negative breast cancer is a very aggressive disease with few standard treatment options. Most patients are treated with off-label therapies. Von Hoff and colleagues reported on a study of 86 patients where the progression-free (PFS) survival on a regimen selected by molecular profiling was compared to PFS on the last chemotherapy regimen. The authors found the regimen selected by molecular profiling offered a 27% survival advantage. In addition, recent data on breast cancer also supports the use of Foundation One testing (Parker, et al). Given the support above, the testing at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.  Final Result: Two reviewers determined that 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 overturned.  Credentials/Qualifications:   All three reviewers are board certified in internal medicine with sub-specialty certification in medical oncology 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 authorization and coverage for Adderall medication. While the patient fits the criteria for a diagnosis of attention deficit hyperactivity disorder (ADHD), the records document a context of relatively recent substance use. Despite having undergone rehabilitation for substance use, the records note repeated misuse of substances in the relatively recent past and a history of misusing Adderall. Further, none of the providers involved in this patients care are recommending treatment with Adderall. In this clinical setting, treatment guidelines recommend a three to six-month period of sobriety from all substances, following which a reevaluation of stimulant treatment of ADHD may be considered. For stimulant treatment, medical literature shows that long-acting formulations allow once-daily simple treatment regimens and are more effective than short-acting preparations, such as Adderall, and less prone to abuse and diversion. In this patients case, Adderall medication is not in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, the requested medication is not clinically appropriate in terms of type, frequency, extent, site, and duration. Therefore, Adderall medication is not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement for residential treatment center services. Findings:  The physician reviewer found that the treatment plan addressed multiple symptoms and diagnoses and presented a reasonable expectation of improvement. The patient was cooperative with treatment and continued to meet goals, resulting in a successful outcome from this treatment intervention. The medical evidence supports the medical necessity of residential treatment during the dates of service in dispute. Children and adolescents often display multiple symptoms following abuse experiences and do not easily reveal trauma in treatment situations. The facility treatment plan recognized the importance of this history, and it appears that intervention was tailored differently in this facility, resulting in more successful intervention. There is ample evidence from psychiatric evaluations, progress notes, and group participation to indicate that the patient made steady progress toward goals throughout the duration of treatment and was discharged with much improved prognosis.  All told, residential treatment center services were medically necessary for the treatment of this patient. Final Result: The reviewers determined that the services at issue were 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 psychiatry with sub-specialty certification in child and adolescent psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for an oral appliance device (E0486). According to the International Classification of Sleep Disorders, Third Edition, (ICSD-3), a diagnosis of OSA is supported by the presence of symptoms such as excessive daytime sleepiness, fatigue, snoring, and non-restorative sleep, as well as comorbidities such as hypertension, psychological disorders, and/or five or more events of obstructive events on polysomnogram or home sleep study. Based on the polysomnogram results, this patient requires treatment for his mild OSA. The patient reports that he could not use CPAP, and his provider recommended an oral appliance. As the patient could not tolerate or refused CPAP treatment, alternative treatment with oral appliance is indicated to treat his symptoms in addition to possible benefit of managing his underlying polycythemia vera. All told, the requested oral appliance device (E0486) is medically necessary for treatment of this patient. 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 internal medicine with expertise 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 a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the Prolaris gene test. Findings:  The physician reviewers found that this patient underwent genomic testing to assist in clinical decision making and to determine whether the patient had low or high risk prostate cancer. Molecular and genomic testing can help patients with low risk disease to make decisions regarding observation versus treatment. Drawbacks include heterogeneity of prostate cancer and uncertainty of potential clinical benefit. Considering this patients age and Gleason score, current guidelines place this patient at high risk and additional testing would therefore not be beneficial for either risk stratification or in decision making. Thus, the Prolaris gene test performed was not 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 the testing at issue was 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: All three physician reviewers are board certified in urology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: A 29-year-old female enrollee has requested authorization and coverage for surgery to make the abdominal wall tighter (abdominoplasty and suction assisted lipectomy) for treatment of the enrollees separation of abdominal muscles and excess skin and not reconstructive in nature. Findings:  The physician reviewer found that according to the American Society of Plastic Surgeons (ASPS), a true hernia repair involves opening fascia and/or dissection of a hernia sac with return of intraperitoneal contents back to the peritoneal cavity. A true hernia repair should not be confused with diastasis recti repair, which is part of a standard abdominoplasty. In addition, Townsend and colleagues noted that, the most common variant of normal anatomy seen in the abdominal wall is diastasis recti. This consists of an upper midline protrusion of the abdominal wall between the right and left rectus abdominis muscles. This abnormality represents a weakness of the linea alba and does not require treatment unless an epigastric hernia occurs in association with the diastasis recti. A review from Hickey and colleagues reported that, correction (of diastasis) is largely cosmetic, and although divarications may be unsightly they do not carry the same risks of actual herniation. Overall, plication of the rectus muscles is not established in the medical literature to be of functional benefit. In this case, the patients condition constitutes an abnormal structure of the body caused by pregnancy. However, the requested surgery is not likely to improve function or create a normal appearance to the extent possible. Abdominoplasty with diastasis repair is a body contouring rather than a functional procedure. Moreover, the requested surgery is not likely to provide more than a minimal improvement in the appearance of the patient. For these reasons, the requested surgery to make the abdominal wall tighter (abdominoplasty and suction assisted lipectomy) is not medically necessary or reconstructive in nature for treatment of this patients medical condition. Final Result: The reviewer determined that the requested surgery is not medically necessary or reconstructive in nature for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Final Result: The reviewer determined that the requested surgery is not medically necessary or reconstructive in nature for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for cognitive processing therapy. The physician reviewer found that submitted documentation supports the medical necessity of the requested services. The patient has a diagnosis of posttraumatic stress disorder. Per the records, the enrollee has not had an evidence-based therapy for the primary psychiatric diagnosis. The patient has expressed a preference for cognitive processing therapy. Although symptomatic, the patient does not have suicidality, aggressiveness, psychosis or active substance use, which is common exclusionary criteria for trauma-focused psychotherapy. The psychology note reported a normal mental status examination and indicated that a stable foundation of skills was needed prior to starting cognitive processing therapy. Of note, the initial sessions of cognitive processing therapy focus on rapport-building, psychoeducation, and the introduction cognitive restructuring, all of which is aimed at establishing a foundational skillset that the therapy builds upon in subsequent sessions. Recent notes stated that the patient denied current suicidal ideation, plans, means, or intent, while mood was euthymic, and the remainder of the mental status examination was reassuringly normal. There was no evidence of substance abuse, violent behavior, psychosis, or a decompensation in baseline functioning. Notwithstanding, although pharmacotherapy is a common intervention, evidence-based, trauma-focused therapies outperform psychotropic medications and represent the first-line treatment for posttraumatic stress disorder, and there is no arbitrary prerequisite medication state needed prior to initiating cognitive processing therapy. Cognitive processing therapy is reasonably expected to improve the patients condition and prevent a more serious episode of illness. The requested services are medically appropriate and consistent with good medical practice. All told, the requested cognitive processing therapy is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested services are 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 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.