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

An enrollee has requested authorization and coverage for a custom, myoelectric elbow-wrist-hand-finger orthosis (EWHFO), the MyoPro. There is adequate data supporting the efficacy of myoelectric orthoses for use with brachial plexopathy. In addition, there is a small volume of literature with limited numbers of patients that show the benefit of using the MyoPro for stroke patients. However, there is a paucity of evidence to support a myoelectric orthosis as the standard of care. Colleagues published a clinical case series report with fewer than 10 patients. Colleagues found benefits in stroke patients using the myoelectric orthosis in 18 patients. Overall, larger prospective randomized studies are needed to support the use of the MyoPro in stroke patients. Furthermore, this patients condition is noted to include spasticity, which may complicate the use of the device. All told, the requested custom, myoelectric elbow-wrist-hand-finger orthosis (EWHFO), the MyoPro, is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Findings:  Three physician reviewers found the requested custom, myoelectric elbow-wrist-hand-finger orthosis (EWHFO), the MyoPro, is not 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 custom, myoelectric elbow-wrist-hand-finger orthosis (EWHFO), the MyoPro, is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in physical medicine and rehabilitation and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

The parent of an 8-year-old male enrollee has requested for an 18-day intensive feeding program for treatment of the enrollees medical condition.   Findings:  Two physician reviewers found that this difficult case involves gastostomy tube transition and oral intake failure. The patients feeding problems are complex and refractory to standard therapies. While additional data regarding the recommended approach is needed, it appears that the only other alternative for this patient is a lifetime of tube feeding and recurrent hospitalizations. All told, there is sufficient evidence that the proposed treatment program is likely to be more efficacious for this patient than standard therapies, which have for the most part failed.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a five-year-old male has requested twelve hours per month of applied behavioral analysis (ABA) supervision services for treatment of his autism.   Findings:  The physician reviewer found that the patients provider and parent are seeking authorization for twelve hours of ABA supervision per month as opposed to the six hours per month authorized by the health plan. ABA therapy is one of the few documented treatments that have been proven to have some efficacy in decreasing the behavioral problems and increasing communication in children with ASD. The above cited evidence demonstrates that ABA therapy is effective in improving communication and socialization in children with ASD. However, none of these extensive reports state the recommended division in total hours between direct interventional therapy and supervision. A review of the scientific evidence did not reveal compelling evidence related to the application of hours between therapy and supervision. A small study by Hayward found that the number of hours spent in clinical intervention and intensive parental managed intensive supervision did not make a significant difference. Rather, it was the total hours of combined treatment that determined efficacy. All told, there is inadequate evidence that twelve hours per month of ABA supervision is medically necessary compared to six hours per month of supervision.In the case of this patient, he has received twelve hours of ABA supervision for nearly the past year which should have afforded sufficient opportunity to educate the family on the required parental contribution to the program. At this point in time, the need for supervision is limited to providing progress reports and suggestions to the patients parents as to the necessary interactions with the patient. Six hours of supervision per month is sufficient for achieving this goal.
Appeal type: Medical Necessity
Decision: Upheld

A 48-year-old female enrollee has requested surgery to repair a fracture of the distal aspect of the nasal bone for treatment of her nasal fracture. Findings:  The physician reviewer found that there is no middle vault collapse or other defect that would be expected to cause nasal airway obstruction.  There is no obvious source of nasal airway obstruction and there is no deformity or step off visible from the nasal bone fracture.  Septal deviation is common in the general population.  Many people have a deviated septum with various degrees of severity and no nasal airway obstruction.  Of note, the mere presence of a scar such as that on the nasal bridge of this patient does not make its removal medically necessary.  In the absence of documentation of unstable scar prone to skin breakdown, impaired function, or symptoms (such as pain or itching), the removal of such a scar would be considered cosmetic in nature and not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: A patient requested authorization and coverage for mefenamic acid (Ponstel). The American College of Obstetricians and Gynecologists (ACOG) recommend treatment of fibroid associated pelvic pain with non-steroidal anti-inflammatory drugs (NSAIDs). The ACOG practice bulletin noted that NSAIDs are effective in reducing dysmenorrhea. Ponstel is a member of the fenamate group of NSAIDs. Studies show Ponstel has analgesic, anti-inflammatory, and antipyretic properties. Per its current U.S. Food and Drug Administration (FDA) indications for use, Ponstel is noted to be a potent inhibitor of prostaglandin synthesis. In the case of this patient, the effectiveness and tolerability of Ponstel has been demonstrated in the medical records provided for review. Specifically, the records indicate that the patients pelvic pain has been effectively managed with this medication. Accordingly, the requested Ponstel is medically necessary for continued treatment of this patients gynecologic related pain.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: Upheld

A 54-year-old female enrollee has requested for a breast MRI performed for evaluation of her breasts. Findings:  The physician reviewer found that the use of breast MRI for screening purposes is limited to patients with known BRCA mutation or a family history of BRCA mutation or three or more first or second degree relatives (on same side of family) with known breast cancer. Based upon the information submitted, the patient has only a single first degree relative with a history of breast cancer and there is no documentation demonstrating a BRCA mutation.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the Afirma Gene Expression Classifier test. Findings:  The physician reviewers found that the cytopathology of the 2 cm thyroid nodule was consistent with AUS. The risk of malignancy is 5-15% in these nodules. The American Thyroid Associations (ATA) guidelines state that for nodules with AUS after consideration of worrisome clinical and sonographic features, investigations such as repeat [fine needle aspiration] FNA or molecular testing may be used to supplement malignancy risk assessment in lieu of proceeding directly with a strategy of either surveillance or diagnostic surgery. The ATA guidelines also recommend taking the patients history, ultrasound appearance and other clinical factors, in making medical and surgical decisions. The benign result prevented the risks of an additional biopsy or diagnostic surgery. As such, the Afirma Gene Expression Classifier test performed was likely to be more beneficial for evaluation of the patient's medical condition. Final Result: 3 of 3 reviewers determined that the testing at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: All three physician reviewers are board certified in internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for skilled nursing facility services. In this case, the medical needs of the patient do not support that the services in issue were medically necessary. The patient had reached a level of function that did not require daily inpatient skilled therapy, and she did not require continued daily skilled nursing services. The requested extension of skilled nursing facility care was not based on medical instability, rehabilitation needs or skilled nursing needs. Inconvenience to the patients family is not a medically necessary reason for staying within a skilled nursing facility. The ability to perform car transfers is not medically necessary prior to discharge home for a patient who is able to toilet, to transfer with standby assistance, and to walk 200 feet. Accordingly, skilled nursing facility services were not medically necessary to treat the patients medical condition during the period in issue.Final Result: The reviewer determined that the services in issue were 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 subspecialty certification in hospice and palliative medicine, and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for microwave ablation. Findings: Two out of three physician reviewers found that microwave ablation is likely to be more beneficial for treatment of this patients condition than any available standard therapy. In this case, due to the solitary recurrence with no evidence of distant disease on her most recent restaging studies, it is reasonable to consider local therapy to her liver lesion. Due to the hepatic location of the lesion, ablation can be considered as an alternative to surgical resection as it is associated with equivalent local control and less side effects than surgery. Available studies have shown that microwave ablation results in a wide range of complete tissue ablation depending on tumor size, with complete ablation common and nearing 100% with smaller tumors. Tumor recurrence rate at ablated sites are very low. Intraoperative and postoperative complications are low. Newer microwave technology demonstrated shorter ablation time and fewer complications. Complications from microwave ablation are minimal. Microwave ablation has a short recovery time, short hospital stay, less morbidity and less cost compared to surgery.Final Result: The reviewers determined that the service at issue is 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 reviewers 1 and 3 are board certified in radiation oncology, and physician reviewer 2 is board certified in interventional radiology; all three reviewers are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 56-year-old female enrollee requested authorization and coverage of a custom wheelchair. The Health Plan denied the request indicating that the requested wheelchair is not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plans denial on the basis that the requested wheelchair is medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 3-year-old male enrollee has requested speech therapy (2 hours per week) and occupational therapy (2 hours per week) for treatment of the enrollees autism.  Findings:  The physician reviewer found that speech therapy is medically necessary for this young patient with autism and a history of expressive and receptive language delays with socialization deficits. In the relevant medical literature, Stone and Yoder evaluated 34 children with autism at 2 years of age with 2-year follow-up to examine factors related to the development of spoken language. The only significant predictors were motor imitation and number of hours of speech and language therapy. The authors concluded that the patients with significant speech and language intervention improved in their language development. In addition, Goldstein reviewed communication interventions for autism in peer-review research articles and found sufficient evidence supporting the effectiveness of interventions to teach communication skills to children with autism. Specifically, language skills make a significant difference in the ability of children to control their environment, especially with disruptive behaviors. As language deficits are one of the core aspects of autism for which speech therapy provides professional guidance on communication development, the requested two hours per week of speech therapy (past and future) has been shown to be medically necessary for treatment of this patients autism related delays. Concerning the requested occupational therapy, this modality is considered a standard treatment intervention for patients with autism. The submitted records indicate the patient has previously had documented delays in fine motor and gross motor abilities. Therefore, I find that the patients previous occupational therapy was medically indicated and necessary. With regard to the requested future occupational therapy, the patients most recent occupational therapy on the date in question (by an in-plan provider) indicated the patient presented with no apparent occupational therapy problems. However, this evaluation did not include a reliable testing measure to determine the extent of the patients fine motor and gross motor abilities. The Vineland Adaptive Behavior Scales-second edition (VABS) and Mullen Early Scales of Learning on the said date found deficits of up to 33% on fine motor abilities. Given the inconsistent results on previous evaluations, the patient should have an objective independent evaluation to determine his occupational therapy needs going forward.
Appeal type: Medical Necessity
Decision: Overturned

A 52-year-old female enrollee has requested a duodenal switch procedure for treatment of her morbid obesity. Findings:  The physician reviewer found that the scientific literature as well as the submitted clinical evidence demonstrates that the proposed duodenal switch procedure is the most appropriate surgical option for this patient and is medically necessary. As the medical literature demonstrates, each of the weight loss procedures currently available carries a risk of complications. These risks vary among procedures. However, in terms of outcome, the duodenal switch procedure offers significant advantage when compared to other bariatric procedures. A study by Buchwald and colleagues showed that the percentage of excess body weight loss (EBWL) averages 70% over the long-term with duodenal switch compared to an average EBWL of 50% with other procedures. Furthermore, this study also found that patients with diabetes experience better results with the duodenal switch than with other procedures. A study of long-term results of duodenal switch by Marceau and colleagues found, In the long-term, DS [duodenal switch] was very efficient in terms of cure rate for morbid obesity and its co-morbidities. In terms of risk/benefit, DS was very successful with an appropriate system of follow-up. Overall, the evidence available to date demonstrates that the duodenal switch procedure offers the best long-term success rate of all the bariatric procedures. It does not require an implantable foreign object (such as the Lap-band procedure) which may require further surgical care or adjustments. Furthermore, the incidence of nutritional deficiencies after duodenal switch can be minimized with careful follow-up.
Appeal type: Medical Necessity
Decision: Upheld

A fifty-nine year-old female with chronic daily headaches characterized as migraine is requesting authorization of Amerge tablets.  The patient has been taking daily Amerge as well as Zomig and Relpax for breakthrough pain.Reviewers Findings:  The reviewing physician found that there is no clinical indication for daily long-acting triptans such as Amerge to be taken in combination with other triptans.  The reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

A 60-year-old female enrollee has requested a skilled nursing facility stay for the treatment of her medical condition. Findings:  The physician reviewer found that this patient received skilled PT/OT and was mostly at a SBA/CGA level and was discharged to a restorative nursing program for maintenance care. The patient refused care at times due to fatigue/pain. Due to the patients medical diagnosis it is expected that the patient will have days of feeling weaker/stronger with her fatigue/endurance level being variable. Hence, in this setting there can be no significant improvement expected with continued daily skilled PT/OT in a reasonable period of time. In addition, further decline could be prevented with a maintenance program.
Appeal type: Medical Necessity
Decision: Overturned

A 55-year-old female enrollee has requested residential treatment center (RTC) care for treatment of her behavioral health condition. Findings:  The physician reviewer found that the RTC services provided during the period at issue were medically necessary for this patient due to her diagnoses of both acute and chronic alcoholism as well as bipolar disorder. This combination of illnesses creates a high rate of suicide in patients, and this particular patient had a history of a suicide attempt. This patients situation was even more dangerous in that she is status post gastric bypass which renders the alcohol concentrations in the blood to rise more rapidly after alcohol ingestion due to altered patterns of alcohol absorption. This patient had recently experienced blackouts, awakening with multiple bruises and unable to remember what happened to her. This type of history is consistent with rapidly increasing blood alcohol concentrations which lead to blackouts. This situation placed her at high risk for injury, apart from her suicide risk. All told, this patient had a complex clinical situation which required an RTC level of care during the time period at issue.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the second CPT code 64636. Findings:  Three physician reviewers found that the submitted records do not document an official pain diary for the medial branch block done prior to the requested radiofrequency ablation. Prior to radiofrequency ablation, the literature recommends using a pain diary for the day to verify when the local anesthetic wore off and not using anything other than a local anesthetic for the test. Moreover, it is possible the patient would have obtained the same relief from a steroid injection alone without also having the increased risk from the radiofrequency ablation. No mention of prior failure from facet injections is done. Also, no mention of a home exercise program is discussed. Finally, the records do not document an examination consistent with facet arthropathy at the requested levels. Thus, the second CPT code 64636 was not likely to have been of greater benefit than other treatment options. Final Result: The reviewers determined that the services at issue were 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: Physician reviewers 1, 2 and 3 are board certified in anesthesiology with sub-specialty certification in pain medicine and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 52-year-old male enrollee has requested a fourth lumbar epidural injection for the treatment of his lower extremity radiculopathy and low back pain. Findings:  The physician reviewer found that the patient has obtained relief of pain with epidural injections and has had a series of three injections in the past. There is no contraindication for a fourth injection, or for the patient to have another series of three injections. This is especially true, if the injections are his only means of relief. He has attempted physical therapy, chiropractic care and massage with no relief. Further epidural injections would be considered appropriate and indicated for this patient.
Appeal type: Medical Necessity
Decision: Upheld

A 42-year-old female enrollee has requested authorization and coverage for removal of breast implants for treatment of a ruptured breast implant. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  Removal of breast implants would be considered medically necessary for the treatment of active infection, impending or actual implant extrusion, painful symptomatic grade IV capsular contracture, or leakage of silicone gel.  The existence of any of these conditions is not documented in the reviewed materials.  It is unlikely that a deflated saline implant in the absence of grade IV capsular contracture or infection would cause any functional deficit.  Based on the information provided, removal of breast implants is not medically necessary for the treatment of this patient. Given the absence of high-grade capsular contracture, capsulectomy is also not medically necessary.