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

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for Lo Loestrin Fe. The use of oral contraceptive pills to mediate the symptoms of perimenopause and medical problems has been supported. This patient has shown improvement in her multiple sclerosis symptoms with the use of low dose oral contraceptive pill.  Given that the patient is approaching the age of menopause, the short-term use of the oral contraceptive pill is reasonable. This patient has demonstrated that a higher dose of estrogen is not tolerated, as it caused an elevation in her blood pressure. In general, the lowest dose of estrogen should be used that is therapeutically effective. Thus, Lo Loestrin Fe 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 obstetrics and gynecology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for Accutane. The provider reports that this patient has tried and failed conservative combination therapy. Accutane is U.S. Food and Drug Administration (FDA) approved for the treatment of moderate to severe acne. Accutane often provides long lasting clearance of severe, scarring acne which has been resistant to other therapies. The use of Accutane can prevent chronic, long-term scarring that can result from persistent nodulocystic acne. Thus, the requested Accutane is supported as medically necessary for treatment of this patients medical condition. 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 dermatology 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 reimbursement for use of a continuous positive airway pressure (CPAP) machine and supplies. The submitted documentation supports the medical necessity of the equipment at issue. In this case, the patient was prescribed CPAP for home use. The medical evidence supports the use of CPAP as the first-line treatment in severe OSA. It is well-established within current practice guidelines that CPAP supplies should be replenished on a periodic basis. This is in part to maximize patient therapy with the devices. Per the records, this patient was noted to have been compliant with the use of his CPAP. Compliance is generally defined as use for four or more hours on 70% of nights within a 30-day period. Therefore, the use of a CPAP machine and supplies was medically necessary for the treatment of this patient.Final Result: The reviewer determined that the equipment at issue was 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 neurology with sub-specialty certification 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: Medical Necessity
Decision: Upheld

The parents of a 26-year-old female enrollee requested authorization and coverage of laser hair removal for treatment of the enrollees medical condition. The Health Plan denied the request indicating that the requested procedure is not medically necessary for treatment of the enrollees folliculitis. Two physician reviewers performed a medical necessity Independent Medical Review. Both of the physician reviewers concluded that the requested therapy is not medically necessary for treatment of the enrollees medical condition at this time. Because both of the physician reviewers concluded that the requested therapy is not medically necessary for treatment of the enrollees medical condition at this time, the Health Plans denial has been upheld at this time.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 62-year-old female with long-standing breast augmentation problems. The patients provider has requested authorization for removal of the suspected ruptured implants and capsulectomy. In addition, the patients provider has requested authorization for bilateral replacement of the implants and mastopexy to the redundant skin/breast. The patients provider previously replaced the patients implants (1983) and performed a bilateral mastopexy with implant exchange (1992). There is MRI evidence documenting bilateral capsular contracture and implant rupture. The Health Plan has authorized removal of the implants and capsulectomy. However, the Health Plan has determined replacement of the implants and mastopexy are cosmetic in nature.The submitted documentation demonstrates the medical necessity for removal of the ruptured implants and capsulectomy. This will aid in the detection of suspicious lesions on mammography in the future. The implants are subpectoral and the result of removal is marginally predictable from a cosmetic standpoint. Breast implant insertion and mastopexy would be performed for the purpose of aesthetic improvement and therefore, these procedures are cosmetic in nature. As such, I have determined that the requested procedures are not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

A 63-year-old female enrollee requested authorization and coverage for a referral to a dermatologist for the treatment of lesions that come and go.  The health plan has denied this request indicating that the requested referral is not medically necessary for treatment of the enrollees medical condition.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer overturned the health plans denial on the basis that the requested referral is medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary:The physician reviewer found that Hunter syndrome, or mucopolysaccharidosis type II, is a lysosomal storage disease caused by a deficient (or absent) enzyme, iduronate-2-sulfatase. It is an X-linked recessive disease, leading to progressive accumulation of glycosaminoglycans in nearly all cell types, tissues and organs.  Characteristic features of mucopolysaccharidosis type II include coarsened facial features, an enlarged head, an enlarged tongue, hypertrophic tonsils and adenoids, irregularly shaped teeth, recurrent otitis media, a distended abdomen due to hepatosplenomegaly, abdominal and/or inguinal hernias, thickened pebbled skin, and short stature. Although the specific combination of signs and symptoms may vary considerably between individuals, the presence of any of the features listed may be suggestive of mucopolysaccharidosis type II. The gold standard for the diagnosis of mucopolysaccharidosis type II is demonstration of deficiency of iduronate-2-sulfatase enzyme activity. Genetic testing of iduronate-2-sulfatase to confirm the diagnosis may be useful in patients with an unusual phenotype or in whom the results of iduronate-2-sulfatase testing are inconclusive.  In this patients case, the iduronate-2-sulfatase activity was zero and other enzyme activity was normal. This, along with the characteristic physical examination features, is diagnostic of mucopolysaccharidosis type II, Hunter syndrome.  In sum, the requested gene testing is not likely to be of greater benefit than other methods of evaluating this patient.  Final Result: The reviewers determined that the requested service are not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: Physician reviewer number one is board certified in pediatrics and clinical biochemical genetics] 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 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.Physician reviewer number three is board certified in 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: Upheld

The patient is a 34-year-old female who has requested reimbursement for fragile X testing. The patient indicates she has a maternal half-sister with attention deficit disorder. As a result, a genetic counselor recommended the patient undergo fragile X testing. The Health Plan has denied coverage for the services at issue on the basis that fragile X testing was not medically necessary.The Health Plans denial should be upheld. While the patient has a maternal half-sister with attention deficit disorder, she does not have a family history of fragile X syndrome or mental retardation. The Health Plan criteria for fragile X testing is medically reasonable and appropriate. The patient does not meet the Health Plans established risk criteria. Furthermore, review of the submitted evidence does not reveal any medical indication for the services at issue. Therefore, I have determined that the services at issue were not medically necessary for evaluation of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

A 54-year-old female enrollee has requested extracorporeal shock wave therapy (ESWT) for treatment of her plantar fasciitis. Findings:  Two physician reviewers found that according to the medical literature, there is some evidence that ESWT can provide a moderate degree of pain relief in selected patients with chronic plantar fasciitis who have failed conservative therapy. However, optimal treatment parameters have not been established, patient selection criteria have not been adequately defined and there is a lack of information regarding the durability of the treatment effect or any long-term adverse effects of ESWT. In addition, there have been conflicting results among the randomized and controlled studies. All told, at this time there is insufficient evidence to conclude that the use of ESWT to treat this patients plantar fasciitis is likely to result in a better clinical outcome compared to standard interventions.
Appeal type: Medical Necessity
Decision: Overturned

The patient has requested authorization and coverage for Orthovisc injections in both knees. Evidence from systematic reviews and randomized controlled trials indicate that although viscosupplementation may relieve knee pain in some patients with osteoarthritis, data has not established which patients will benefit. Guidelines from the American Academy of Orthopedic Surgeons (AAOS) indicate that the data on safety and efficacy of viscosupplementation remain inconclusive. As such, the AAOS does not currently recommend viscosupplementation as standard treatment for osteoarthritis of the knees. Viscosupplementation is reserved for patients with a history of lasting benefit from prior injections and in cases where the remaining options are limited. In this case, the patients treatment options are limited to total knee arthroplasties in the presence of mild tibiofemoral arthritis and severe patellofemoral arthritis. The provider does not recommend over-the-counter NSAIDs due to comorbid diabetes. All told, the requested Orthovisc injections in both knees are medically necessary for 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 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

The parent of a male enrollee requested acute inpatient psychiatric hospitalization services for medical treatment of the enrollees behavioral health condition.  Findings:  The physician reviewer found that a portion of the services were medically necessary for treatment of the patients medical condition. Early discharge would have been premature and more than likely would have resulted in undue morbidity and prompt readmission. Although the provider recommended that the patient would benefit from ongoing observation and stabilization, the medication regimen was maintained without modification and there was no update to the treatment plan or specific articulation rationalizing the medical necessity of the acute setting to achieve the clinical recommendation. In sum, acute inpatient services were no longer reasonably expected to improve the patients condition as he was not suffering from an acute psychiatric syndrome. Based on the documentation provided, discharge to a less restrictive setting would have been safe, appropriate and consistent with good medical practice. Thus, the initial acute inpatient psychiatric hospitalization services were medically necessary for treatment of the patients behavioral health condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for resumption of skilled nursing facility (SNF) services including physical therapy and occupational therapy. The records document that this patient has a history of oropharyngeal dysphagia likely related to history of recent prolonged and complicated medical course related to COVID-19 infection, resulting intubation and tracheostomy. Per the providers notes, the patient presented to the emergency department following hospital discharge. The patient was transferred to a long-term care facility. The patient has an indwelling nasogastric tube, and the patient has reported slightly worsening shortness of breath compared to baseline. The patient recently failed bedside swallow screens and continues to require nasogastric feedings. On review of the records from the emergency department reassessment, the patient was in borderline status. Based on the patients persistent symptoms related to COVID-19 infection including tachycardia, oxygen desaturation, and weakness, the patient requires intensive rehabilitation services including skilled nursing care and the physical and occupational therapy services provided in a SNF treatment setting (Udina, et al.; Agostini, et al.). Given these findings, the requested resumption of SNF services including physical therapy and occupational therapy is medically necessary for 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 internal medicine with subspecialty certification in infectious diseases 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 Citrulline for the treatment of the enrollees medical condition.  Findings:  The physician reviewer found that the requested medication has been established as medically necessary for treatment of the patients medical condition. Ornithine transcarbamylase (OTC) deficiency disorder can have serious effects if not treated.  Patients with OTC deficiency benefit from treatment with Citrulline. Citrulline is indicated to maintain a normal rate of protein synthesis. Without Citrulline the patient would be at risk of having high ammonia levels with severe consequences. Therefore, Citrulline has been established as medically necessary for treatment of the patients OTC deficiency. 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 pediatrics and pediatric 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the bilateral breast tomosynthesis for the evaluation of the enrollees medical condition. Findings:  The physician reviewers found that tomosynthesis is a technique that was developed as a problem solving adjunct to routine mammography. Patients who have dense breasts benefit most from breast tomosynthesis which has the ability to separate out the overlapping structures with the possibility of demonstrating an otherwise occult tumor. In this case, the patient has extremely dense breasts. It is specifically those patients who have dense breasts that can benefit most from tomosynthesis. Final Result: Two of 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: Physician reviewers number one, two, and three are board certified in diagnostic radiology and actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for the SPRINT peripheral nerve stimulation (PNS) system. Findings:  The physician reviewer found that the records provided for review document that the patient presents with right foot and ankle pain. The records document that the patient is status post right superficial peroneal nerve block with two hours of relief with anesthetic, but she failed to obtain adequate relief with the steroid. The patients provider has recommended treatment with PNS. The SPRINT PNS system is a minimally invasive, nondestructive treatment modality that has been shown to provide relief of neuropathic pain of the lower extremities and trunk (Hanyu-Deutmeyer and Pritzlaff). In patients who have failed to improve with conservative care including a multimodal treatment approach, PNS may be an effective and minimally invasive treatment option (Deer, et al.). A diagnostic right superificial peroneal nerve block with local anesthetic reportedly yielded two hours of relief, but the patients relief was not sustained with the steroid. PNS of the right peroneal nerve is appropriate as the next treatment option to provide this patient with more sustained pain relief. Given this support, the requested SPRINT PNS system is 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 SPRINT PNS system is 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 likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewer 1 is board certified in anesthesiology with subspecialty certification in pain medicine and is actively practicing. Physician reviewer 2 is board certified in anesthesiology with subspecialty certification in pain medicine and is actively practicing. Physician reviewer 3 is board certified in anesthesiology with subspecialty certification in pain medicine and is actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for opium tincture 1% (equivalent to morphine 10 mg/mL) 7 mL every six hours.The submitted documentation supports the medical necessity of the requested medication. The treatment options for short bowel syndrome are limited, and the patient has already failed other options. Current medical literature supports the use of opium tincture for the treatment of short bowel syndrome. Parrish and DiBaise noted, Tincture of opium should be considered in patients with short bowel syndrome who have failed therapy with loperamide or diphenoxylate. American Society of Colon and Rectal Surgeons guidelines state that opioids result in decreased intestinal motility, decreased intestinal secretion, and increased absorption. Opiates are recommended as safe and effective for the treatment of chronic diarrhea. Tincture of opium has been effective in this patients case. Therefore, opium tincture 1% (equivalent to morphine 10 mg/mL) 7 mL every six hours 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 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.