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

The parent of a five year old male enrollee has requested one hour of occupational therapy per week for the treatment of the enrollees autism. Findings:  The physician reviewer found that the American Occupational Therapy Association (AOTA) supports the use of OT services for the purpose of treating functional deficits in patients with autism as outlined in their guidelines. This patient has sensory and fine motor delays that are affecting his ability to attend to self-care as well as his independence in the community. Review of the submitted information demonstrates that twice-monthly therapy has been inadequate to address the patients functional deficits. For instance, while OT is generally helpful in improving dressing skills, this patient has not achieved adequate gains in this area from his current therapeutic regimen. As such, it is medically appropriate and necessary to initiate weekly OT sessions, which focus on development of adequate short-term objectives and long-term goals related to ADLs and fine motor skills for community play.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 15-year-old male enrollee has requested growth hormone (GH) therapy with Humatrope for the treatment of the enrollees linear growth failure. Findings:  The physician reviewer found that the pituitary microadenoma may be an incidental finding lacking clinical relevance, the patients crossing of percentile growth lines is remarkable as is his response to GH therapy. Thus, partial GH deficiency and gonadotrophin deficiencies may explain his growth failure. Given these clinical indications, GH therapy should be continued while growth response is sustained.
Appeal type: Medical Necessity
Decision: Upheld

The parent of an 18-year-old male enrollee requested authorization and coverage of discharge to home with RN shift care for the treatment of TBI (traumatic brain injury).  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.
Appeal type: Experimental/Investigational
Decision: Upheld

A 55-year-old male enrollee requested authorization and coverage of robotic-assisted laparoscopic radical prostatectomy. The Health Plan denied the request indicating that the requested procedure is considered investigational for treatment of the enrollees prostate cancer.Three physician reviewers performed an experimental/investigational Independent Medical Review. Two of the three physician reviewers concluded that the requested procedure is not likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy. One of the three physician reviewers concluded that the requested procedure is likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy. Because two of the three physician reviewers concluded that the requested procedure is not likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy, the Health Plans denial has been upheld.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:   An enrollee has requested Sovaldi and ribavirin for 24 weeks for treatment of his hepatitis C virus.  Findings:  Three physician reviewers found that according to the American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases, for retreatment of patients with genotype 2 who previously failed therapy with sofosbuvir plus ribavirin, the recommended regimen is either daclatasvir plus sofosbuvir (with or without ribavirin) for 24 weeks or sofosbuvir plus ribavirin plus peginterferon for 12 weeks. Currently, the combination of daclatasvir plus sofosbuvir has not been approved by the U.S. Food and Drug Administration (FDA) for genotype 2 patients. The use of Sovaldi and ribavirin for 24 weeks in patients who have previously failed Sovaldi and ribavirin for 12 weeks is not supported by clinical studies. As such, the request for Sovaldi and ribavirin for 24 weeks is not medically indicated for treatment of the patients hepatitis C, genotype 2a.  Final Result:  Three reviewers 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: One reviewer is board certified in gastroenterology and is actively practicing. Two reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology 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: Experimental/Investigational
Decision: Upheld

A 54-year-old female is requesting for cervical artificial disc surgery for treatment of her neck pain. Findings:  Three physician reviewers found that there are insufficient well-designed clinical trials showing superior long-term results of artificial cervical disc surgery over cervical fusion. The requested procedure remains of unproven efficacy at this time, as additional studies demonstrating long-term safety and benefit are needed.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:   An enrollee has requested Trulicity and Vascepa for treatment of his hypercholesterolemia and diabetes mellitus.  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medications.  The records document diabetes and hypertriglyceridemia.  In this circumstance, treatment with lifestyle changes and medication is appropriate and recommended by current guidelines.  The patient has requested coverage for Vascepa.  However, the Health Plan denied this requested due to an inadequate trial with two of the following medications: gemfibrozil (Lopid), micronized fenofibrate or Niacin.  These alternative medications are effective in the treatment of hypertriglyceridemia, and it is medically appropriate to try these drugs prior to Vascepa.  Glucagon-like peptide-1 (GLP-1) agonists such as Trulicity are not first-line agents to treat diabetes, are relatively new drugs, and the long-term risks and benefits of these agents are not known.  In this patients case, there is a lack of support for Trulicity over other medications in this class. Therefore, the use of Trulicity over another medication in this class, such as Bydureon, is not medically necessary.  All told, Trulicity and Vascepa are not medically indicated for the treatment of this patient. Final Result: The reviewer determined that the requested medications 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 internal medicine with sub-specialty certification in cardiovascular disease 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 authorization and coverage for continued treatment with a non-contracted pediatric endocrinologist for the treatment of diabetes.  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.
Appeal type: Medical Necessity
Decision: Overturned

A 37-year-old female enrollee has requested laparoscopic adjustable gastric banding surgery for treatment of her obesity.  Findings:  The physician reviewer found that the patients chart demonstrates that she has tried many diets in the past but was unable to maintain the weight loss. Several years ago she did lose some weight, but in the past couple of years, both her weight and BMI have increased. The American Society of Bariatric Surgery (ASBS) 2004 consensus conference statement, As long as a candidate has tried to lose weight by various means they should not be required to complete formal non-operative obesity therapy as a precondition for bariatric surgery(Buchwald). The authors also commented that, Long-term weight loss is difficult to achieve with diet, exercise, and pharmacotherapy. Most patients who present for bariatric surgery have already failed multiple attempts to achieve a sustained weight loss by using nonsurgical treatment options. Jamal and colleagues have also demonstrated that mandated pre-operative dietary counseling is an obstacle to patients access for surgical treatment of morbid obesity and has no impact on weight loss outcome or post-operative compliance. Applying the basic criteria set forth by the ASBS, the 1991 National Institutes of Health (NIH) consensus conference weight criteria for bariatric surgery of a BMI greater than 40 is still reasonable today.
Appeal type: Medical Necessity
Decision: Overturned

A 59-year-old female enrollee has requested an endonasal tumor removal (endonasal transphenoidal approach) for the treatment of her suprasellar mass. Findings:  The physician reviewer found that the patient should have surgery to have this tumor removed. How it is accomplished is a matter of debate in the neurosurgical literature. The advantages of the supratentorial approach are that it is easier for most neurosurgeons and allows better removal of the tumor from the chiasm. The disadvantages are that it is more invasive and has the possibility of more complications. The transnasal endoscopic approach is less invasive, does not require mobilization of the brain and can decompress the tumor from below the chiasm and avoid manipulation of the optic nerve. It is a more complex procedure with a steeper learning curve and ideally should have better results in the hands of an experienced surgeon trained in the approach. It is medically reasonable for the patient to undergo a transnasal endoscopic approach.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Euflexxa injections for treatment of the enrollees bilateral knee pain.Findings: The physician reviewer found that the request for Euflexxa injections is medically necessary for treatment of the patients medical condition. The peer-reviewed literature supports the use of hyaluronan therapy for treatment of the patients medical condition. Bannuru and colleagues concluded that hyaluronic acid was the best pharmacologic intervention for knee osteoarthritis in their meta-analysis. The authors found that hyaluronic acid was found to be better than injected placebo or injected corticosteroids. The literature review by Trojian and colleagues recommends hyaluronan acid for appropriate knee osteoarthritis patients. In this case, the patient presents with chronic bilateral knee pain. Clinical examination findings are consistent with reported radiographic evidence of moderate medial compartment and moderate to severe patellofemoral compartment osteoarthritis of both knees. She has failed to adequately improve with anti-inflammatory medications, analgesic medications, physical therapy, and corticosteroid injections. A series of Euflexxa injections have been recommended for both knees as the only option other than knee replacement. She wants to delay total knee replacement given her young age. Evidence based medical peer-reviewed literature supports the use of viscosupplementation injections for the treatment of pain in patients with osteoarthritis of the knee. Viscosupplementation has been found to be safe and effective and allow for delay of total knee replacement, and more effective than corticosteroid injections. Therefore, the requested Euflexxa knee injections are medically necessary for treatment of the patients medical condition. Final Result: The reviewer 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: 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

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for consultation with a nephrologist and kidney function test/renal function test (KFT/RFT). The records document that this patient presents with multiple diagnoses including thalassemia, prediabetes, iron deficiency anemia, and ventricular septal defect. The patients medical conditions require a multidisciplinary approach to appropriately plan and administer her care. The patients caregiver has requested a consultation with nephrology. Leung and colleagues noted that, Although proteinuria is usually benign in the form of transient or orthostatic proteinuria, persistent proteinuria may be associated with more serious renal diseases. The presence of proteinuria supports an indication for the requested KFT/RFT. Given this patients elevated long term-risk for end stage renal disease and risk of renal disease complicating other problems, evaluation and treatment by a nephrologist is appropriate. All told, the requested consultation with a nephrologist and KFT/RFT are medically necessary for treatment of this patient. 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 internal medicine with subspecialty certification in nephrology 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

Findings:  The physician reviewer found that The patient has requested authorization and coverage acupuncture. Based on the current peer-reviewed medical literature, the requested acupuncture is medically necessary for treatment of this patients nausea related to her infertility treatment regimen. Morehead and Salmon reported that the efficacy of acupuncture has been proven for nausea and vomiting related to pregnancy, in patients receiving chemotherapy, and in postoperative, pediatric, and female patients. This patients nausea secondary to infertility medications may respond favorably to treatment with acupuncture as noted in the medical literature (Lee, et al.). The patient should undergo a trial of treatment with acupuncture, and additional treatment sessions should be supported with a positive response. Given this support, the requested acupuncture 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.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for an epidural steroid injection. The American Society of Interventional Pain Physicians (ASIPP) concluded that for lumbar disc herniation with radiculitis, the evidence is good for short-term and long-term relief with local anesthetics with steroids. Evidence is superior in contained disc herniation. Epidural steroid injections (ESI) have a clinically established role in the short-term management of low back pain when the pain is associated with symptoms of nerve root irritation and/or low back pain due to disc extrusions and/or contained herniations, and the pain is unresponsive to conservative treatment, including but not limited to pharmacotherapy, exercise or physical therapy. In this case, the patient developed radiating back pain into the left buttock, thigh and calf area associated with numbness. The physical was notable for diminished sensation in the left thigh and calf area. Her magnetic resonance imaging (MRI) reveals a new corresponding new disc herniation compressing the L3 nerve root on the left. Her conservative treatment to this point included non-steroidal anti-inflammatory drugs (NSAIDs), anticonvulsants, opioids and steroid burst with no benefit or improvement. She attempted physical therapy but was unable to participate due to pain. Based on the available medical records for review, the requested epidural steroid injection is medically necessary for the patients lumbar radiculopathy.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 anesthesiology subspecialty certification in pain management 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 56-year-old female enrollee has requested for a WalkAide Neuro Stimulator/Functional Electrical Stimulator (FES) for treatment of her medical condition.   Findings:  Two physician reviewers found that functional electrical stimulation devices (such as the WalkAide) for the treatment of foot drop are experimental, investigational and unproven with respect to effectiveness and outcomes in comparison to conventional orthotic options for foot drop related to multiple sclerosis or other neurological conditions. More research of a disinterested nature is needed to further evaluate the device manufacturers claims regarding these types of devices. Of note, there are two active trials listed in the NIH clinical trials database that are still recruiting participants. These ongoing trials support the contention that the efficacy of the WalkAide device has not been established in the literature.
Appeal type: Medical Necessity
Decision: Upheld

A 43-year-old female enrollee has requested duodenal switch surgery for treatment of her morbid obesity. Findings:  The physician reviewer found that the duodenal switch is an appropriate standard treatment for morbid obesity in the well-selected patient. It has been shown through numerous published papers to be safe, effective and durable. It has a morbidity and mortality that is comparable to other restrictive type procedures with its own risk benefit profile. Like any procedure for weight loss, long-term follow-up is essential to success.  It has been shown to have the best resolution of diabetes of any weight loss procedure.  Although the requested procedure is a standard treatment for morbid obesity, the medical necessity of a duodenal switch for this patient has not been established.  The submitted documentation does not include a dietary evaluation that shows the patient to have appropriate understanding and ability to comply with a post bariatric diet.  All patients should complete a thorough multidisciplinary evaluation that includes a dietary evaluation in addition to other components such as medical clearance, behavioral clearance and surgical evaluation. The submitted dietary evaluation from June 2010 did not document that the patient was ready for surgery.  It is well within standard guidelines that documented dietary readiness be obtained before proceeding with duodenal switch.  All told, the requested duodenal switch is not medically indicated for this patient at this time.
Appeal type: Medical Necessity
Decision: Overturned

The patient has requested authorization and coverage for a consultation with a dermatologist. A dermatologist is the appropriate provider to diagnose and treat hair loss. As noted in this patients records, the primary care provider referred the patient to a dermatologist to perform a work-up to determine the etiology of the patients hair loss. Some skin diseases that present as hair loss can be diagnosed by evaluation of the hair and scalp. Once the etiology of the patients hair loss has been determined, the provider can help formulate a plan for treatment. All told, the requested consultation with a dermatologist is medically necessary for this patient.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 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: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for parenchymal tissue ablation of the liver using NanoKnife technology for treatment of the enrollees epithelioid hemangioendothelioma. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services in this patients case.  At this time, there is insufficient published evidence to assess the safety or impact of the requested services on health outcomes or patient management. There is limited long-term survival and recurrence data regarding the use of the NanoKnife technology in this clinical setting. The patient is currently stable, with no change in the liver lesions over multiple CT scans.  He also has normal liver function tests.  All told, the requested parenchymal tissue ablation of the liver using NanoKnife technology is not medically necessary for the 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 interventional radiology and diagnostic radiology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.