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

Nature of Statutory Criteria/ Case Summary:  The enrollees parent requested authorization and coverage for Easystand Zing Size 2 Multi-Position Stander. According to the medical record, the enrollee has spastic hemiplegic cerebral palsy and intractable epilepsy. She is unable to walk or stand on her own, unable to sit upright on her own, and uses a wheelchair for mobility. Her physician has prescribed an adaptive stander/walker (Easystand Zing Size 2 Multi-Position Stander) since the enrollee needs a gait trainer due to lack of balance and spasticity. The enrollee had a trial with the Zing Stander in two sessions with the ability to adduct 30 degrees. The physician requires the enrollee to be standing and weight bearing daily to promote healthy bone density and efficient digestive function. According to the medical literature, passive range of motion, bowel function, pain, activity, and participation may improve for some adolescents at gross motor function classification system (GMFCS) level V, through use of a stander. The intensive active stretching in a dynamic stander is an effective new conservative clinical treatment of ankle plantarflexor contracture in children with cerebral palsy (CP). Standing frames are beneficial for contracture management. Standing should occur thirty minutes, five times a week for a positive impact. Supporting standing devices allow the user to attain and maintain a standing up/partial standing position.  Literature details beneficial effects of standing devices on range of motion, as well as spasticity and bowel function for participants of all ages.  Within the submitted documentation it was noted the enrollee has trialed the requested device while in therapy with benefit.  Final Result: Three of the three reviewers determined that the requested service is likely to be more beneficial than any available standard therapy for treatment of the enrollees medical condition.Credentials/Qualifications: Three reviewers are board certified in physical medicine and rehabilitation 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: Urgent Care
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested air and ground ambulance services on an emergent or urgent basis.  Findings: The physician reviewer found that review of the submitted documentation demonstrates that a prudent layperson would not believe she was experiencing an emergency medical condition. Based on the records provided the patients presentation was not consistent with the above definition of an emergency medical condition. Her medical condition was not precarious as prior to her flight she was at home without monitoring of physiologic parameters. In addition, the patient denied any pain or discomfort. There is a lack of clinical documentation demonstrating that the patient presented with symptoms of sufficient severity such that the absence of immediate medical attention could reasonably be expected to result in placing the patients health in serious jeopardy. In sum, the patient was not suffering from a serious medical condition that was likely to place the patients health in serious jeopardy, cause serious impairment to body functions or cause serious dysfunction to a body organ or part. Thus, the services at issue did not meet prudent layperson criteria for emergency care.  Moreover, it has not been established that criteria for urgently needed services were met on the date in dispute. The patient presented status post left hip surgery. The medical records from the air ambulance report that she was picked up at home without monitoring of physiologic parameters. Once in the ambulance she denied pain or discomfort. There is a lack of documentation supporting that the services at issue were necessary to prevent serious deterioration of the health of the patient. Based on the documentation submitted for review a prudent layperson in a similar situation would not have believed urgent medical attention was necessary to prevent serious deterioration of ones health. In sum, based on the patients clinical presentation during the date in dispute the patient did not meet prudent layperson criteria for urgently needed services. Final Result: The reviewer determined that the patients symptoms did not meet prudent layperson criteria for emergency care or urgently needed services. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: The reviewer is board certified in physical medicine and rehabilitation with sub-specialty certification in neuromuscular medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a 14-year-old male enrollee has requested for Genotropin growth hormone therapy for treatment of the enrollees idiopathic short stature. Findings:  The physician reviewer found that at 54 and 14.5 years, the patient had adult levels of testosterone and a bone age advanced by about two years. He had an IGF-1 level of 343 ng/ml. He would not qualify for growth hormone therapy on the basis of idiopathic short stature under the FDA guidelines since he is already at the adult height required by the agency.
Appeal type: Experimental/Investigational
Decision: Upheld

A 56-year-old male enrollee requested authorization and coverage of minimally invasive percutaneous lumbar discectomy for the treatment of back pain.  The health plan denied the enrollees request indicating that the requested treatment is experimental.Three physician reviewers performed an experimental/investigational Independent Medical Review.  Each of the three physician reviewers concluded that a minimally invasive percutaneous lumbar discectomy is not likely to be more beneficial for treatment of the enrollees back pain than any available standard therapy.  Because all three physician reviewers concluded that the requested treatment is not likely to be more beneficial for treatment of the enrollees medical condition than any available standard therapy, the review organization upheld the health plans denial.
Appeal type: Medical Necessity
Decision: Overturned

A female enrollee requested authorization and coverage of peglyated interferon (PEG-Intron) and rebetron for the treatment of chronic hepatitis C.  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 overturned the health plans denial on the basis that the requested services are  medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a three-year-old female with significant autism. She has been treated with applied behavioral analysis, with reported benefit. The patients parent has requested reimbursement for the past therapy as well as authorization and coverage for continued therapy. The Health Plan has denied this request on the basis that applied behavioral analysis was/is not medically necessary.Review of the relevant published literature on autism and its treatment reveals that the most effective treatment consists of applied behavioral analysis. It is a well-researched, evidence-based technique of intervention for children with autism spectrum disorders. Applied behavioral analysis uses an intensive, behaviorally based approach to intervention often referred to as discrete trials instruction, among other strategies. In the case of this patient, the submitted clinical information demonstrates she has shown some improvement with applied behavioral analysis. As such, the therapy was medically indicated and should be continued for one year with re-evaluation by the patients provider at the end of the one-year period. Accordingly, I have determined the therapy at issue was/is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for endoluminal ablation of varicose veins for treatment of his varicose veins. Findings:  The physician reviewer found that the documentation submitted for review supports the medical necessity of endoluminal ablation of varicose veins in this clinical setting. The patient has significant symptoms in the area of the varicose veins that have persisted despite significant weight loss and palpable pedal pulses. While there is no documentation of use of compression stockings, it is unlikely that compression stockings would be a successful plan considering the patients body habitus. The duplex demonstrates reflux in the symptomatic segments of the left GSV. For a morbidly obese patient to have obvious, visible varicose veins, the tributary veins would be expected to be quite large. The recommendation for left lower extremity stab phlebectomies along with ablation of the left GSV is both reasonable and medically necessary for treatment of the patients medical condition. Final Result: The reviewers 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 vascular 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

A 32-year-old female enrollee requested authorization and coverage of gastric bypass surgery. The Health Plan denied the request indicating that the requested procedure is not medically necessary for treatment of the enrollees morbid obesity.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plans denial on the basis that the requested procedure is medically necessary depending upon the results of a psychological evaluation.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a four-month-old male requested authorization and coverage for Enteral formula (Enfacare 22 calories ready to feed formula). The Health Plan denied this request indicating that the requested formula is not medically necessary for treatment of the enrollees stated condition of pre-term birth and slow growth without nutritional supplementation. Findings:  The physician reviewer found that the requested Enfacare 22 calories per ounce (cal/oz) is not medically necessary for this patient. This patient was born late preterm, with a birth weight of 2695 grams, which is above the 50th percentile for his sex and gestational age. His discharge weight, of 3025 grams, was also above the 50th percentile. He was not considered to be failure to thrive, his feeding problems resolved and he was able to breastfeed. Additionally, the patient was not noted to have any chronic or debilitating conditions. The literature indicates that preterm infants should not be overfed in the attempt to promote catch-up growth (Merenstein and Gardner). Late preterm birth does not necessitate caloric supplementation, particularly in the absence of medical problems. At two months of age, the patient weighed 9 pounds 15 ounces almost double his birth weight of 5 pounds 15 ounces. The general rule of thumb is that a baby should double its birth weight by four months of age. This patients growth velocity demonstrates more than adequate growth and does not support the need for continued use of Enfacare 22 cal/oz at this time. The requested Enfacare 22 calories per ounce (cal/oz) is not medically necessary for this patient.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for occipital nerve block (CPT 64450). Findings:  The physician reviewer found that records provided for review document that this patient with occipital neuralgia has failed traditional migraine therapies including Tylenol, Advil, Excedrin, and muscle relaxant medications. Her provider has recommended treatment with an occipital nerve block. As noted in the medical literature, greater occipital nerve blocks have been shown to provide well-selected patients an effective treatment modality in the treatment of headaches secondary to greater occipital neuralgia. Greater occipital nerve block intervention can significantly alleviate pain, reduce the number of headache days, and decrease the need for medications in this patients clinical setting. Therefore, the requested occipital nerve block (CPT 64450) is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings:  Two of the three physician reviewers found the requested occipital nerve block (CPT 64450) is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewers 1, 2, and 3 are board certified in neurology 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

A 64-year-old male enrollee has requested intensity modulated radiation therapy (IMRT) for treatment of his esophageal cancer. Findings:  Two physician reviewers found that IMRT is a radiation planning and delivery tool available to the radiation oncologist to better shape the radiation dose distribution, and therefore minimize the radiation doses to normal structures. IMRT is of use when there is concern about sparing normal tissues from high-dose radiation exposure. There is a growing amount of literature on the use of IMRT for esophageal cancer, with most studies demonstrating a dosimetric advantage (Zhang and colleagues and Chen and colleagues). However, there is little clinical outcome data available. There is also a growing amount of literature supporting the use of IMRT in patients with gastric cancer, albeit a slightly different clinical situation than with this patient as gastric cancer patients generally undergo radiation after gastrectomy. Nevertheless, the principles of using IMRT to spare normal tissue from radiation do apply for both gastric cancer and esophageal cancer. The volume of heart, bowel and cord receiving in excess of 45-50 Gy correlates with acute and late toxicity to these organs. Reducing the high-dose radiation exposure to these organs is known to reduce toxicity. IMRT is a tool that enables the reduction of dose to surrounding organs. As the patients physician indicates, the heart and spinal cord are in close proximity to the target tumor. Given the proximity of the target tumor to critical structures, IMRT is clinically warranted in this patients particular situation.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a two-year-old male enrollee has requested speech therapy services for evaluation and treatment of the enrollees speech/language delay.  Findings:  The physician reviewer found that as noted by Nelson and colleagues, speech and language development is considered by experts to be a useful indicator of a childs overall development and cognitive ability and is related to school success.  The authors noted that identification of children at risk for developmental delay or related problems may lead to intervention services and family assistance at a young age when chances for improvement are best.  Speech and language delay must be taken seriously in young children because the long-term consequences may be substantial.  As noted by Law and colleagues, approximately 6% of children have speech and language difficulties.  These authors noted that children whose difficulties persist into primary school may have long-term problems concerning literacy, socialization, behavior, and school attainment.  These reviewers concluded that there is a positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulties.  This patient has expressive speech and language delay that adversely impacts his ability to communicate with those around him.  If not addressed, his communication delays may adversely affect interactions with peers and caregivers.  Studies have shown that speech and language therapy can result in significant improvement in children such as this patient.  All told, the requested speech therapy services (evaluation and treatment) are medically indicated for this patient.
Appeal type: Medical Necessity
Decision: Upheld

A sixty-three year-old female with metastatic melanoma to the lungs is requesting authorization to be treated with Sutent (sunitinib).  Reviewers Findings:  The reviewing physician found that there is no evidence to support the use of sunitinib in the treatment of melanoma.  The reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

A 42-year-old male enrollee requested authorization and coverage of a corneal transplant. The Health Plan denied the request indicating that the requested procedure is not medically necessary for treatment of the enrollees limbal stem cell deficiency.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested procedure is not medically necessary.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested quantitative sensory testing for evaluation the enrollees neuropathic symptoms. Findings: Two physician reviewers found that the testing at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Quantitative sensory testing is able to capture and quantify stimulus-evoked negative and positive sensory phenomena, and as such should become standard if not a critical tool in neuropathic pain research and practice. Although quantitative sensory testing is not indicated for every patient, it can be useful for patients with evidence suggestive of a peripheral neuropathy without a definitive etiology. The testing at issue was able to further classify this patients neuropathy in preparation for appropriate therapeutic intervention. Given the clinical documentation submitted for review, quantitative sensory testing was reasonable and within standard clinical practices. Accordingly, the quantitative sensory testing has been established as likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: Two of three 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 neurology and are actively practicing. The reviewer 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for posterior tibial neurostimulation for treatment of the enrollees urinary urgency. Findings:  The physician reviewers found that there is evidence in the peer-reviewed literature from randomized trials and prospective observational trials supporting the clinical utility and impact on patient management of posterior tibial neurostimulation in patients with urinary urgency and frequency, as in this case. However, most trials have a small number of patients with short term follow-up. American Urological Association guidelines recommend that clinicians should offer behavioral therapies, such as bladder training, bladder control strategies, pelvic floor muscle training and fluid management, as first-line therapy to all patients with overactive bladder. Behavioral therapies may be combined with pharmacologic management. Clinicians should offer oral anti-muscarinics or oral beta 3-adrenoceptor agonists as second-line therapy. If a patient experiences inadequate symptom control and/or unacceptable adverse drug events with one anti-muscarinic medication, then a dose modification or a different anti-muscarinic medication or a beta 3-adrenoceptor agonist may be tried. Patients who are refractory to behavioral and pharmacologic therapy should be evaluated by an appropriate specialist if they desire additional therapy. The guidelines rate posterior tibial neurostimulation as a recommended third-line therapy. In this patients case, the documentation does not support the use of less invasive second-line therapies.  Therefore, the superior efficacy of posterior tibial neurostimulation has not been established.  Final Result: 2/3 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 reviewer number one is board certified in urology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.Physician reviewer number two is board certified in urology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.Physician reviewer number three is board certified in urology 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.