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

A 58-year-old male has requested Egrifta for treatment of his lipodystrophy secondary to HIV medications.  Findings:  The physician reviewer found that abdominal lipodystrophy constitutes an abnormal collection of adipose tissue. In this patients case, the lipodystrophy may be related to taking the medications for treatment of HIV. Currently, as stated in the press release from the FDA, Egrifta is noted to decrease abdominal fat. However, functional improvement has not been clearly studied or shown as judged by the FDA. As noted by Falutz and colleagues, tesamorelin (Egrifta) might be useful for the treatment of HIV-infected patients who have an increase in abdominal girth and dyslipidemia in the context of receiving antiretroviral therapy. Some data suggest that Egrifta may also improve lipids in HIV-infected patients with excess abdominal fat accumulation, but these findings need to be confirmed. Based on the FDA approval, Egrifta may be a strategy to create a normal appearance to the extent possible. This patient is documented to have a severe condition of abdominal protuberance without significant subcutaneous fat. He has a severely abnormal condition that may be related to an increase in visceral adipose tissue (VAT) from treatment of his HIV disease. This abnormal condition is demonstrated in the photographs provided for review. A confirmatory CT scan is appropriate to document that the major contribution to this condition is from VAT and not from other causes, as recommended by the treating provider. On confirmation that the patients condition is from VAT, then Egrifta should be authorized as reconstructive and therefore medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

A 49-year-old female has requested gastric bypass surgery at the time of removal of Lap-band for treatment of her obesity.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services in this patients case.  She underwent placement of a gastric band via a laparoscopic approach six years ago.  Beginning three years later, she has had progressive complaints of daily emesis.  On a date at issue, she weighed 180 pounds.  Approximately three years later, there was no significant change in her weight, as she weighed 181 pounds on this date.  Her provider recommended gastric band removal due to the persistent and frequent emesis.  Due to concerns of weight regain following gastric band removal, conversion to Roux-en-Y gastric bypass was recommended.  The current medical evidence does not support the requested services in this patients case.  Her body mass index is less than 35, and there are operative risks involved with the requested services.  All told, the requested gastric bypass surgery at the time of removal of the Land-band is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

A 49-year-old male enrollee has requested anterior lumbar interbody fusion for treatment of his lumbar radiculitis at L5-S1. Findings:  The physician reviewer found that this patient has chronic low back pain with evidence of multilevel abnormalities on MRI scan. However, there is no history or findings on physical examination to implicate the L5-S1 disc to be his pain generator to warrant spinal fusion of that segment. He has no symptoms or findings of a lumbar radiculopathy (Tarulli and Raynor). He has no evidence of angulation, instability, scoliosis, spondylolysis, spondylolisthesis, recent trauma or infection to warrant spinal fusion at this time (Milliman Care Guidelines and Bambakidis, et al).
Appeal type: Experimental/Investigational
Decision: Upheld

A 36-year-old male has requested coverage for past usage of 30 days of EKG real time cardiac monitoring for evaluation of his heart palpitations.  Findings:  Three physician reviewers found that the patient has a history of hyperlipidemia and symptoms of intermittent palpitations associated with upper extremity weakness. A clinic note documents symptoms at least daily. An electrocardiogram (EKG) was reported to be normal and a stress echocardiogram (ECHO) was reported to be normal. A 24 hour Holter monitor was performed and revealed no significant dysrhythmias. Real time cardiac telemetry was scheduled and performed through the time frame at issue. Based on the records provided for review, the patient has intermittent palpitation symptoms and no significant dysrhythmias identified on 24-hour Holter monitoring. In this circumstance if further monitoring for a cardiac dysrhythmia were thought to be medically necessary then non-real time monitoring devices such as extended or serial Holter monitoring or event monitoring should be sufficient for identification of both symptomatic and asymptomatic dysrhythmias. Use of continuous off-line 24-48 hour Holter monitoring should be able to effectively identify symptomatic or asymptomatic dysrhythmias that occur frequently. Likewise, self-activated non-real time and non-continuous monitoring devices (event recorders) should be effective at recording symptomatic dysrhythmias during less frequent symptoms. In less common cases of infrequent asymptomatic dysrhythmias that require identification, non-real time (off-line) monitoring devices with auto-triggering capability should be sufficient. There is no documentation to indicate the patient is not able to effectively manage these standard monitoring devices. Immediate recognition and reporting of dysrhythmias through a call center provided by real time mobile telemetry services is not needed in this patients case and has not been shown to improve health outcome compared to standard monitoring techniques.
Appeal type: Medical Necessity
Decision: Upheld

A 61-year-old male enrollee requested transcranial magnetic stimulation services for medical treatment of his bipolar disorder.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  Transcranial magnetic stimulation has been endorsed by the American Psychiatric Association for the acute phase treatment of major depressive disorder.  However, the recommendation does not extend to bipolar disorder.  Although some preliminary positivism can be found in the medical literature regarding the application of transcranial magnetic stimulation therapy for patients with bipolar disorder, there is an absence of well-controlled and adequately powered exploratory and confirmatory studies.  Thus, the safety and appropriateness of transcranial magnetic stimulation for this indication has not been established.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for surgery to remove the Nuss bar.Findings:  The physician reviewer found that the submitted documentation and relevant literature demonstrates the medical necessity of the requested surgery. Removal of the pectus Nuss bar is medically necessary. In addition, the original provider should be the one who removes the Nuss bar, as complications can occur including the need to free the bar from embedded bone and the need for possible bilateral dissection. Given that four years have passed since the original surgery, the likelihood of bone ingrowth and the need for further dissection supports the original provider as likely to be best suited to perform the removal procedure. Final Result: The reviewer determined that the requested surgery 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 thoracic 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 61-year-old male enrollee has requested for a hearing aid replacement for treatment of his bilateral sensorineural hearing loss.  Findings:  The physician reviewer found that in the peer reviewed medical, Saunders and Cox noted that considerable counseling is required to create realistic expectations in patients regarding use of hearing aids. Further, Goggins and Day found that at three years minor interventions for the hearing aid are usually required, but does not indicate that the devices need replacement. Given that this patients hearing is stable and he currently has a functioning hearing aid, the request for a replacement device has not been established as medically necessary at this time.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/ Case Summary:  The enrollees parent is requesting authorization and coverage for Applied Behavior Analysis (ABA) therapy. The patient is a nine-year-old male currently diagnosed with absent corpus callosum, Dandy-Walker malformation, developmental delay, epilepsy, and developmental speech and language disorder. Neurology evaluation indicates delayed milestones, with his receptive skill at around 80%. He displayed difficulty with non-verbal expressions, rigid thinking patterns, fixated interests and hyper/hyposensitive reactions to stimuli. The physician noted these were all characteristics of developmental delay and not autism spectrum disorder (ASD). However, the patient started applied behavior analysis (ABA) therapy. The record indicates he still did not meet ASD criteria, but had delayed social skills and repetitive behavior. He received physical therapy (PT), occupational therapy (OT), speech therapy (ST) and vision therapy once a week. An ABA report indicates the progress the patient was making with his current regimen and recommended an increase in treatment; from six hours per week to ten hours per week, with six hours of supervision per month for the next six months. He currently utilizes OT, PT, ST, adaptive physical education (PE) and a one-to-one aide. He attends a regular school with an individualized education program. The medical literature indicates applied behavior analysis (ABA) therapy is a behavioral intervention used to treat autism spectrum disorders in which the patients progress is tracked and measured.  Such therapy emphasizes communication, play, academic, social, work, community, and self-care.  ABA has been shown to be effective in improving communication, social skills, and management of problem behavior for children with ASD.  Literature support for applied behavior analysis is limited to patients with autistic spectrum disorder. The program is specifically designed to address the needs of patients with ASD. Based on literature review and DSM criteria, ASD is distinctively different from developmental delay. His physician applied the DSM criteria measures to appropriately rule out the diagnosis of ASD for this patient. While a suspicion for ASD is noted for the patients behavioral and social delay, neither the doctor nor the regional center has provided a follow-up DSM evaluation to support a definitive diagnosis of ASD for this patient. Rather, the physician considered the patients behavior was also related to attention deficit hyperactive disorder (ADHD) symptoms, and is treating the patient for ADHD. Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in psychiatry and child & 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 53-year-old male enrollee requested authorization and coverage of Pravachol. The Health Plan denied the request indicating that the requested medication is not medically necessary for treatment of the enrollees hyperlipidemia.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plans denial on the basis that the requested medication is medically necessary.
Appeal type: Experimental/Investigational
Decision: Overturned

A 54-year-old male enrollee requested positron emission tomography (PET) for medical evaluation of his tonsil cancer.  Findings:  Two physician reviewers found that the services at issue were and are likely to be more effective for this patient than other available options. In this clinical setting the PET scan incorporates a diagnostic-quality anatomic imaging component, which can correctly identify clinically inapparent synchronous tonsil cancers and assist in the evaluation for distant disease. In addition, there is support in the medical literature for PET scans in order to direct the choice of biopsy sites at the time of panendoscopy, thereby increasing accuracy in detecting singular or synchronous primary cancers (Price and Pickles; Strobel, et al).
Appeal type: Medical Necessity
Decision: Upheld

A 61-year-old female enrollee requested the compounded prescription drug tobramycin sulfate for the treatment of the enrollees medical condition.   Findings:  The physician reviewer found that the current medical evidence does not support the medication in this clinical setting.  Per the peer-reviewed medical literature, the use of topical intranasal antibiotics is no more effective than topical nasal saline in this patients case.  The current medical literature suggests that the addition of topical intranasal antibiotics is no more beneficial than intranasal saline alone in the management of symptoms of purulent nasal discharge following sinus surgery.  Additionally, there is a lack of evidence that the patient had clinically positive bacterial growth requiring either oral or other topical antibiotic usage.  The provider stated that previous nasal cultures had shown bacterial growth, but there is no documentation of the results of those cultures.  All told, the compounded prescription drug tobramycin sulfate was not medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary:   An enrollee has requested Botox injections for treatment of her medical condition.  Findings:  Three physician reviewers found that Vulvodynia is a complex problem that is difficult to treat as the disease process is multifactorial without one specific etiology, and clinically can present in different ways and can change over time. The American College of Obstetricians and Gynecologists (ACOG) has addressed this complex condition and does not include Botox injections as a first- or second-line therapy. Botox does appear to be safe but it is currently not U.S. Food and Drug Administration (FDA) approved for this indication and not part of the ACOG algorithm of management. For these reasons, the requested Botox injections are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: Three reviewers determined that the services at issue were not and 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:  All three reviewers are board certified in obstetrics and gynecology 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: Overturned

A 46-year-old female enrollee has requested a CT scan of the abdomen and pelvis for an evaluation of her abdominal pain. Findings:  The physician reviewer found that CT scans are a commonly used diagnostic test to evaluate the abdomen and pelvis. Indications for CT scan include pain or suspected masses. The patient was adequately evaluated prior to the study. CT scan of the abdomen and pelvis was an appropriate diagnostic examination for further evaluation of the patients symptoms.
Appeal type: Experimental/Investigational
Decision: Upheld

A 57-year-old male enrollee has requested laparoscopic restrictive vertical gastroplasty/gastrectomy for treatment of his morbid obesity. Findings:  Two physician reviewers found that the record indicates the patient is not considered a viable candidate for the Roux-en-Y gastric bypass  procedure because of his need to take NSAIDS and the risk of ulcer disease. This is a reasonable assessment. However, the Lap Band can provide everything a vertical gastroplasty/gastrectomy can provide. The Lap Band procedure has no staple line and has lower morbidity rates because there is no risk of leakage, erosion or mesh migration. The Lap Band is also adjustable over time versus the fixed characteristic of the vertical gastroplasty/gastrectomy. Although the vertical gastroplasty/gastrectomy is a novel approach, support cannot be provided for the procedure at this time as there are other safe and proven surgical options available.
Appeal type: Medical Necessity
Decision: Upheld

A 59-year-old female enrollee requested authorization and coverage of a bone density test.  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: Upheld

A 21-year-old male enrollee requested Vyvanse 80 mg for medical treatment of his attention deficit hyperactivity disorder (ADHD).  Findings:  The physician reviewer found that there is a lack of data supporting the medical necessity of Vyvanse dosing in excess of the U.S. Food and Drug Administration (FDA) recommended limit of 70 mg per day.  The literature does not support the request for Vyvanse 80 mg per day as medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 37-year-old male enrollee has requested for an intensive outpatient chemical dependency program for treatment of his chemical dependency. Findings:  The physician reviewer found that the patient had been using multiple drugs and alcohol for a very long time and had a significant risk of relapse. These factors support the need for on-going intensive outpatient intervention for continued sobriety.
Appeal type: Medical Necessity
Decision: Upheld

A 53-year-old female enrollee  requested breast implant removal (CPT code 19371, periprosthetic capsulectomy, breast; CPT code 19328 removal of intact mammary implant) for treatment of her capsular contracture.  Findings:  The physician reviewer found that the requested services are not medically necessary for treatment of the patients medical condition. Capsular contracture is a well-recognized complication following augmentation mammaplasty and can cause pain. The treating surgeon notes that she has been having no significant discomfort, but is complaining of the hardness of the implants. This does not support that there is a significant functional deficit. Overall, based on the medical documentation provided for review, there is a lack of support that a significant functional deficit exists and that the patient has failed non-operative medical management. Thus, the medical necessity for implant removal with capsulectomy has not been established.
Appeal type: Medical Necessity
Decision: Overturned

The parents of a seven-year-old male with a history of Downs syndrome and autism with significant speech delay are requesting coverage of both past and future speech therapy.Reviewers Findings:  The reviewing physician found that in comparing the progress reports it is clear that although the gains are slow, the patient is making gains in functional communication.  The reviewing physician found that the Health Plan denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of the enrollee has requested reimbursement for the cytogenetic microarray testing. The clinical utility of chromosomal microarray is well established, and is now considered first-line genetic testing for patients with developmental delays and autism spectrum disorders. In a study by researchers, a retrospective chart review of chromosomal microarray testing was performed on patients with developmental delay, intellectual disability, autism spectrum disorders and congenital anomalies. Findings in this study demonstrated that chromosomal microarray results influenced medical care in the majority of patients by precipitating medical referrals, diagnostic imaging, or specific laboratory testing. Thus, there is adequate support for chromosomal microarray analysis in this patients evaluation given the concern for intellectual disability. For these reasons, the cytogenetic microarray testing was likely to be more beneficial for evaluation of this patients medical condition than any available therapy.One reviewer found that the cytogenetic microarray testing was not likely to be more beneficial for evaluation of this patients medical condition than any available therapy.Final Result: Two of the 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:  One reviewer is board certified in genetics with subspecialty certification in clinical cytogenetics and is actively practicing. One Reviewer is board certified in pediatrics with subspecialty certifications in neurodevelopmental behavioral pediatrics and genetics and is actively practicing.  One Reviewer is board certified in pediatrics 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 cervical spine magnetic resonance imaging (MRI) for evaluation of the enrollees cervicalgia. Findings:  The physician reviewer found that there are no red flags to indicate immediate MRI scan of the cervical spine without a trial of conservative management. In particular, a cervical spine x-ray series showed degenerative changes and no fracture or malalignment. There is no history of trauma, infection or cancer. Neurological exam is essentially unremarkable. Absent a trial of conservative management for six weeks, the requested MRI of the cervical spine is not medically necessary for evaluation of this patients neck pain. Final Result: The reviewer determined that the requested diagnostic procedure is not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in 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.