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

The patient is a 27-year-old female with a body mass index (BMI) of 46. The patient has undergone a psychological evaluation and has been deemed an appropriate candidate for weight loss surgery. She wishes to undergo a gastric bypass procedure. The Health Plan has denied authorization for the requested procedure on the basis that it is not medically necessary for treatment of the patients medical condition.With a BMI of 46, the patient meets accepted national medical necessity criteria for consideration of weight loss surgery. Furthermore a psychological evaluation has determined the patient is an appropriate candidate for weight loss surgery. Roux-en-Y gastric bypass is medically indicated and medically necessary for treatment of this patients morbid obesity. Furthermore, scientific evidence demonstrates that once a morbidly obese patient has been identified as an appropriate candidate for weight loss surgery from a medical and psychological standpoint, further conservative attempts at weight loss are not necessary. The study referenced above demonstrates that surgery has the best long-term outcome for the morbidly obese. Therefore, I have determined that the requested procedure is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Overturned

A 63-year-old female enrollee has requested continued speech therapy/cognitive rehabilitation services for treatment of her medical condition. Findings:  Three physician reviewers found that the medical records indicate that the patient has had prior stroke, with residual deficits and impairments.  The current medical literature supports the requested services in this clinical setting.  The study by Wan and colleagues showed that an intensive rehabilitation program for patients with non-fluent aphasia led to structural changes in the right hemisphere, which correlated with improvements in speech production.  In this patients case, therapy notes show gradual continuing progress towards goals.  Per the medical literature, recovery post stroke occurs at varied paces, and can continue for many months or even years.  Thus, speech therapy/cognitive rehabilitation services were and are likely to be more effective than other treatment options.
Appeal type: Experimental/Investigational
Decision: Upheld

An 18-year-old male enrollee has requested for percutaneous intradiscal electrothermal annuloplasty (IDET) for treatment of his low back pain.   Findings:  Three physician reviewers found that IDET has not been approved or been found beneficial for the treatment of axial back pain. There are no long-term clinical studies showing that this procedure would be efficacious in this setting. The patient is a young male with complaints of back pain. An IDET procedure is not optimal treatment for ongoing complaints of axial pain and is not likely to result in a superior clinical outcome for this patient.
Appeal type: Medical Necessity
Decision: Overturned

A 63-year-old female enrollee has requested anesthesia services during a colonoscopy for treatment of her medical condition. Findings:  The physician reviewer found that the American Society of Anesthesiologists states that monitored anesthesia care requires the presence of an anesthesiologist or certified registered nurse anesthetist for patients at an above average risk for undergoing standard upper or lower gastrointestinal endoscopic procedures. Per the American Society for Gastrointestinal Endoscopy, monitored anesthesia care is indicated for patients who are pregnant, morbidly obese or at increased risk for airway obstruction due to a significant anatomic variant.  Additionally, they note that monitored anesthesia care is indicated for patients who are potential difficulty to sedate due to alcohol or substance abuse, individuals with planned complex procedures and patients with adverse reaction or inadequate response to moderate sedation.  This patient was status post sigmoid resection, thus increasing the potential for a complex procedure. She also had documented issues with previously used conscious sedation.  Thus, she met the outlined criteria per the American Society for Gastrointestinal Endoscopy for use of monitored anesthesia care.
Appeal type: Medical Necessity
Decision: Upheld

The enrollee is a 47-year-old male who complains of severe dizziness and pressure in his head. He states that these problems make it difficult for him to work. He has seen his primary care physician. He has also been seen by a neurologist. The neurologist addressed many varied medical issues including the patients chronic headaches, mild chronic dysequilibrium, episodic vertigo, and positionally related lower extremity paresthesias. Specifically regarding the patients complaints of headache and dysequilibrium, no further neuroimaging was recommended, but he recommended referral to a neurotologist for further evaluation. The patients neurologic exam was documented as entirely normal.The Health Plan denied the referral to a neurotologist and has authorized referral to an otolaryngologist. The Health Plan felt there was no information that indicates a neurotologist evaluation was necessary, stating the patient has already had evaluations and consultations in the past. Evaluations date back to 1988 with an MRI exam and a consultation concerning dysequilibrium. The patient has requested an independent medical review requesting referral to a neurotologist.I support the Health Plans finding that this patient can be seen by an otolaryngologist or a neurologist. All board certified otolaryngologists are well trained to evaluate dizziness and dysequilibrium. This is a basic component of their specialty training. A consultation with an otolaryngologist has already been authorized. There is no information indicating that a neurotologist needs to evaluate this patient. Therefore, I have determined that the requested referral is not medically necessary for the evaluation of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

The patients parent has requested authorization and coverage for speech therapy services (a reevaluation for speech therapy and two 60-minute sessions per week). Liu and colleagues note, The ability to communicate effectively with others is central to children's development. Delays or disruptions due to isolated expressive language delay, articulation errors, multiple sound production errors with motor planning deficits, or mixed expressive and receptive language delay, often bring widespread consequences. Capone Singleton reports that late talking children who do not receive professional intervention are placed at risk for life-long disability. OHare and Bremner emphasize the need for comprehensive speech and language assessment, along with speech therapy, for children with speech and language difficulty. In this case, the records note that the patient has been compliant with attending therapy sessions and has been making progress towards goals, albeit slowly, in excess of incremental progress. In this clinical setting, given that discontinuation of speech therapy would place the patient at increased risks of disability, mental health disorder, and behavioral issues due an inability to communicate, and as continued speech therapy will optimize the patients communication potential, the requested services are medically indicated. Therefore, speech therapy services (a reevaluation for speech therapy and two 60-minute sessions per week) are medically necessary to prevent disease, disability, and other health conditions or their progression, to promote physical and mental health and efficiency, and to correct or ameliorate any physical or behavioral conditions. 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 neurology with special certification in child neurology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a Xiidra 5% droperette. Donnenfeld and colleagues describe lifitegrast ophthalmic solution 5.0% as the first medication approved in the U.S. for the treatment of the signs and symptoms of dry eye disease (DED). Haber and colleagues report that lifitegrast has a novel mechanism of action and is safe and effective for the treatment of DED. In this case, the patient has a diagnoses of dry eye syndrome. In this clinical setting, the requested medication is medically indicated. Therefore, a Xiidra 5% droperette 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 ophthalmology 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 44-year-old male enrollee requested authorization and coverage of an inpatient evaluation of his chronic peripheral neuropathic leg pain.  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: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested breast tomosynthesis for evaluation of her medical condition. Two physician reviewers found that breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than available standard modalities. Despite the lack of long term studies supporting increased survival rates using digital breast tomosynthesis, the addition of the technique to screening digital mammography has gained worldwide popularity due to the associated decreased callback rates and increased detection of small cancers. Thus, the addition of tomosynthesis to standard digital mammography is more beneficial than using digital mammography alone. Therefore, breast tomosynthesis was likely to be more beneficial for evaluation of this patient than standard modalities. Final Result: Two reviewers determined that the diagnostic procedure 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 diagnostic radiology 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 was evaluated by a pediatric endocrinologist for short stature. The patients initial evaluation included multiple labs that were normal, a normal physical exam, and a bone age that was two years delayed. Based on the patients initial evaluation, he underwent growth hormone (GH) stimulation testing with clonidine and arginine, which demonstrated a peak GH of 20 ng/dL (with clonidine). He was diagnosed with idiopathic short stature based on normal GH stimulation testing and a height that was 2.3 standard deviations (SDs) below the mean for his age. At issue in this case is whether the medication Genotropin is medically necessary for the treatment of the patients medical condition. Guidelines concluded that the impact of GH on idiopathic short statute remained unclear, and that the U.S. Food & Drug Administration approval should not obviate the need for a thorough investigation of the cause of the short stature. Updated guidelines stated that further studies are needed to clarify the benefits and long-term risks of GH treatment in the population of patients with idiopathic short stature.In this case, the patients response to GH stimulation was robust, ruling out GH deficiency. In addition, the patients delayed bone age suggests a combination of idiopathic short stature and constitutional delay of growth and puberty. The submitted documentation does not include any longitudinal height data prior to 2018, and one explanation for this patient having fallen further on the growth curve is that his peers are undergoing a pubertal growth spurt. Medical records suggests that the patients increase in height after starting GH was more likely secondary to a pubertal growth spurt than the use of recombinant GH. Under these circumstances, Genotropin is not medically necessary to treat the patients medical condition.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 pediatrics with a subspecialty certification in pediatric endocrinology 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 patients parent has requested authorization and coverage for Gamifant (emapalumab-lzsg) infusions Gamifant (emapalumab-lzsg) infusions. The records provided for review document that this patient has severe systemic juvenile idiopathic arthritis with recurrent episodes of macrophage activation syndrome and hemophagocytic lymphohistiocytosis (MAS-HLH). The patient was treated with Gamifant during the most recent hospitalization, which was discontinued prior to discharge as the episode of MAS-HLH had improved. The patients provider has recommended additional doses of Gamifant to complete an 8-10 week course. As noted by the U.S. Food and Drug Administration (FDA), Gamifant is indicated for the treatment of patients with primary HLH with refractory, recurrent, or progressive disease or intolerance to HLH therapy. Gamifant is recommended for use during an episode of HLH and should be continued until the patient no longer requires therapy for the treatment of HLH. Based on the available data in the medical literature, the requested additional doses are appropriate for this patient given the severity of disease. A case report by Gabr and colleagues involved a patient with macrophage activation syndrome who was treated as an inpatient with Gamifant and then received four additional weekly doses of Gamifant. The authors reported that this treatment regimen resulted in the patients disease going into remission. Moreover, this patient has exhausted most, if not all, therapies indicated for the treatment of patients with systemic juvenile idiopathic arthritis and macrophage activation syndrome. For these reasons, the requested Gamifant (emapalumab-lzsg) infusions are medically necessary for 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.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a one-year-old female enrollee has requested authorization and coverage for a licensed nursing professional (registered nurse (RN), licensed vocational nurse (LVN), public health nurse, or licensed home health aide) performing home health care services for treatment of the enrollees premature birth.  Findings:  The physician reviewer found that based on review of the available records, this one-year-old patient now has a corrected age of approximately nine months. At 10 months of age, she was able to scoot and could tentatively sit. These developmental parameters, when adjusted for prematurity, indicate that the patient is developing normally. The problem is the unavailability of the patients mother as a caregiver secondary to severe diabetes with multiple complicating problems. The patients care is being shared by the patients paternal grandfather and a paternal step-aunt, both of whom cannot be continuously available. The patients medical needs are relatively simple. The patient requires frequent oral feedings supplemented by gastrostomy feedings during the day and a continuous gastrostomy feedings at night. However, this care does not require the services of a skilled caregiver such as a licensed vocational nurse or home health aide. The grandfather and aunt are under stress caring for this patient and her mother but have provided adequate care. The patients medications are relatively simple and can be given via gastrostomy if the patient refuses them orally. Given that this care does not require the services of a licensed nursing professional registered nurse, licensed vocational nurse, public health nurse, or licensed home health aide, the requested services are not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The parents of an 18-year-old male enrollee have requested  for inpatient psychiatric center treatment for treatment of the enrollees condition. Findings:  The physician reviewer found that there was no indication that the patient was profoundly depressed, oppositional, suicidal or homicidal. He was not acting out in an overly aggressive or disturbed manner.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a two-year-old male enrollee has requested for speech therapy for treatment of the enrollees speech delay.  Findings:  The physician reviewer found that the patient has delays in receptive and expressive language of approximately one year behind his peers. A pivotal point with regard to this patients case is that laryngeal or oropharyngeal anatomical abnormalities are not necessary for abnormal language development or abnormal motor behaviors that are seen in children with language delays. At issue is the notion that plasticity in the developing brain still exists, and can be utilized to improve overall neurologic health. Thus, specific treatment can be used to help induce brain plasticity, with the ultimate goal of retraining neural circuitry not compromised by the underlying pathogenetic processes that give rise to receptive and expressive speech delays.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for lidocaine 5% patches for treatment of the enrollees back pain. Findings:  The physician reviewer found that based on the current medical literature and the presented clinical records, lidocaine 5% patches are not medically necessary for treatment of the patients medical condition. One study states that lidocaine patch 5% appears to be effective as an add-on therapy for osteoarthritis pain. The use of up to four patches, changed q24h, provides effective analgesia  without  anesthesia  and  reduces  stiffness,  disability,   and   QOL [quality of life]  impairment   in   patients   who   have responded  incompletely  to  prior  analgesic  therapy. Although there is medical literature supporting the effectiveness of lidocaine patches, there is a lack of evidence for its use in this case. The Health Plans criteria requires the patient trial gabapentin and one other oral analgesic, in addition to lidocaine cream. In this case, the patient has tried hydrocodone/acetaminophen, two different anti-inflammatories, and capsaicin cream. The Health Plans step-up criteria is medically appropriate and reasonable in this clinical setting. Therefore, in the absence of the patients trial and failure of lidocaine cream and gabapentin at a minimum dose of 1800 mg per day and one other oral analgesic, the request for lidocaine 5% patches have not been established as medically necessary for treatment of the patients medical condition. 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 physician reviewer is board certified in anesthesiology with sub-specialty certification in pain 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: Urgent Care
Decision: Overturned

A 58 year old female has requested emergency room services for treatment of her recurrent retinal detachment.  Findings:  The physician reviewer found that a prudent layperson in this situation would have sought immediate medical attention. Proliferative vitreoretinopathy (PVR) is a condition that develops as a complication of retinal detachment due to a break in the retina, or rhegmatogenous retinal detachment. In this disease, retinal pigmented epithelial (RPE) cells come into contact with inflammatory factors called cytokines, which then cause the RPE cells to proliferate and migrate. These RPE cells then cause membranes that contract and pull on the retina, causing further retinal detachments. PVR is a serious condition that is difficult to treat surgically. Risk factors include pre-existing PVR, duration of retinal detachment, size of the retinal hole or tear, and vitreous hemorrhage, or bleeding in the vitreous cavity of the eye.Given what is known about PVR, a prudent layperson would have sought immediate medical attention on the date of service in question. Without prompt intervention, an individual with PVR would be at risk for blindness in the affected eye. A prospective, observational case series by Tseng and colleagues found that long retinal detachment duration was significantly correlated with PVR prevalence and severity. Because of the difficulty of treating severe PVR, this finding supports earlier, rather than delayed, surgical intervention in the case of retinal detachment due to PVR. Given the importance of timely intervention in this setting, the patients clinical findings support the need for immediate medical treatment in this case.