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

The patients parent has requested authorization and coverage for Goodnites brand diapers. The current management of this patients incontinence includes diapering in addition to intermittent catheterization. The medical records do not document skin care issues requiring specific treatment in the perineum or genital area. However, individual patients have varying degrees of success with specific products and often have a period of trial and error until they achieve their best personal regimen. The fact that two different diaper brands are part of this patients successful regimen suggests that the unique benefits are likely due to design similarities found in multiple brandings. All told, the requested Goodnites brand diapers are medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested medical supplies 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 urology with subspecialty certification in pediatric 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.
Appeal type: Medical Necessity
Decision: Upheld

A 54-year-old female enrollee has requested a colonoscopy for evaluation of her left lower quadrant abdominal pain, bloating and constipation.  Findings:  The physician reviewer found that the patient underwent colonoscopy on the said date and 2 small polyps were removed by snare polypectomy. She had a CT scan of the abdomen which was remarkable for diverticulosis with no evidence of diverticulitis. The patient has had lower abdomen pain for a couple years and was treated with Kenalog with bupivacaine injections. In effort to formulate appropriate guidelines for the colon cancer surveillance, the American College of Gastroenterology (ACG) indicates that it is important to stratify patients at their baseline colonoscopy into high risk and low risk groups based upon the pathology of their colon polyps and diagnosis of colon cancer. Patients with one or two adenomas measuring 1 cm or less, with low grade dysplasia should have their next follow-up colonoscopy in 5-10 years. The precise timing within this interval should be based on other clinical factors such as prior colonoscopy findings, family history, and the preferences of the patient and judgment of the provider. A patient with a family history of colon cancer in the first-degree relative or adenomatous polyps in any first-degree relative before age 60, or in 2 or more first-degree relatives at any age, should have colonoscopy every 5 years. If follow-up colonoscopy is normal or shows only 1 or 2 small tubular adenomas with low-grade dysplasia, then the interval for the subsequent examination should be 5 years. In this case, the patient was determined to have 2 small polyps measuring less than 1 cm that were tubular adenomas. Therefore, the patient should have surveillance colonoscopy after five years. Consistent with these findings, the requested repeat colonoscopy has not been shown to be medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

A 59-year-old female enrollee requested authorization and coverage of acupuncture.  The Health Plan denied the request indicating that the requested treatment is not medically necessary for the treatment of the enrollees pain.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plans denial on the basis that the requested treatment is medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 2-year-old female enrollee has requested for speech therapy for treatment of the enrollees speech delay. Findings:  The physician reviewer found that there is robust medical literature supporting speech therapy in this population. Children with speech delay can be readily treated (Law, et al.) and cognitively normal children are ideal candidates for successful speech therapy (Goorhuis-Brouwer and Kniff). Speech therapy has been found to be efficacious in the treatment of speech delays in young children (Emmanuel, et al.). More specifically, 2-year-olds who tested below the 10th percentile for age have been shown to benefit from speech therapy (Emmanuel, et al. and Buschman, et al.).
Appeal type: Experimental/Investigational
Decision: Overturned

A 60-year-old female has requested an MRI of the breast for evaluation based on her personal history of breast cancer.  Findings:  Three physician reviewers found that the patient has a family history of breast cancer in her mother and grandmother.  She has a personal history of breast cancer.  Per the medical records, she presented with a lump, and core biopsy revealed invasive ductal cancer.  She is status post right lumpectomy performed three years prior.  This was followed by re-excision one year later.  A bilateral MRI was performed nine months following and revealed no sign of malignancy.    Per the medical records, the original tumor was not seen on conventional mammogram.  The patients provider has recommended a repeat MRI of the breast.  The Health Plan has denied coverage for the requested diagnostic procedure and reported that MRI of the breast is investigational for the evaluation of this patient.  In this patients case, the requested diagnostic procedure is likely to be superior over other available tools for evaluating this patient.  The requested diagnostic procedure is the most sensitive technique available for breast cancer detection in this patients case. This patient has already been evaluated with a breast MRI.  In this patients case, the requested diagnostic procedure will provide a valuable comparison for any change to indicate possible malignancy.  Additionally, the initial cancer was not demonstrated by mammography.  All told, MRI of the breast is likely to be more effective than other methods of evaluating this patient.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential eating disorder treatment. The Health Plan has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavioral issues.The documentation provided does not support the medical necessity of the services at issue in this clinical setting. Given that the patient was not medically compromised, there is data supporting that inpatient treatment such as a residential treatment center does not provide advantages over outpatient management. The standard of care is to treat patients in the least restrictive environment possible. A study found first-line inpatient treatment does not provide advantages over outpatient management, and that patients who do not respond to outpatient treatment do poorly on transfer to inpatient facilities. In the Handbook of Assessment and Treatment of Eating Disorders, it states that, A PHP [partial hospitalization program] is appropriate when meal supervision is needed without requirement for 24-hour supervision. PHP admission generally requires that patients be at or above minimally acceptable weight (e.g., greater or equal to 80% of ideal body weight) and maintain other evidence of medical stability. This patient was medically stable. The patient was motivated for treatment. The patient was cooperative with staff and participated in group sessions and individual sessions. The patient did not have any suicidal or homicidal ideation. She did not have any psychosis, hallucinations, or mania. Therefore, the medical necessity of the residential eating disorder treatment has not been established for the treatment of this patients medical condition.Final Result: The reviewer determined that the services at 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 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 a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 6 year 10 month old male with a diagnosis of autism. He has been receiving speech therapy intermittently from the Swain Center since August 2004. He has also been receiving speech therapy twice a week for 25 minutes from the school district. The Swain Center is recommending the patient continue to receive private speech therapy twice weekly in addition to the therapy provided by his school. At issue is whether the requested speech therapy is medically necessary for the patients diagnosis of autism.The Health Plans denial should be upheld. Upon review of the submitted clinical information, including the physical therapy evaluations, the recommended goals for the patient address receptive and expressive language deficits, which are educationally-based goals, rather than pragmatic language goals and functional community skills.  Furthermore, the submitted records demonstrate that over the last six months, none of the goals listed have been fully met and daily notes document little progress. Thus, it is unlikely that the requested therapy will result in measurable improvement in the patients functional status. Therefore, I have determined that the requested therapy is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

The parent of an enrollee has requested authorization and coverage for Functional Formularies Nourish. The patient has tried and failed Elecare, Elecare Jr., and Kate Farms Pediatric Peptide. It can be used for meal replacement or to supplement, for both oral and enteral use. It meets the dietary restrictions of the six-food elimination diet. Records reflect that the patient has tried samples of Nourish and has responded well, with decreased symptoms and improved weight gain. Functional Formularies Nourish treats the patients eosinophilic esophagitis, prevents complications from the disease, and promotes weight gain and growth. The requested Functional Formularies Nourish therefore promotes the health of the patient, prolongs life, and prevents the progression of her health condition. Accordingly, the requested Functional Formularies Nourish is medically necessary to treat the patients condition.Final Result: The reviewer determined that the requested product is medically necessary to treat the patients condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in pediatrics, with subspecialty certification in pediatric critical care 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

A 53-year-old male enrollee has requested Vytorin for the treatment of his high blood pressure and cholesterol. Findings:  The physician reviewer found that according to the criteria set forth by the National Cholesterol Education Program (NCEP) Expert Panel, this patient has two risk factors for coronary heart disease: hypertension and his age (greater than 45 years). His 10-year Framingham risk of coronary artery disease is less than 10%, and his goal LDL is less than 130 mg/dL (Peter and colleagues). The cholesterol level at which it is reasonable to initiate drug therapy in this patient is 160 mg/dL (Third Report of the NCEP Expert Panel). Given that the patients LDL was only 164 mg/dL without therapy, there is inadequate justification for the use of Vytorin as a first-line agent to reduce his cholesterol level.  Vytorin is indicated for patients who require a greater than 40% reduction in LDL cholesterol level or who do not have an adequate response to single agent therapy. Any of the HMG-CoA reductase inhibitors (e.g., simvastatin, pravastatin, atorvastatin) are appropriate first-line agents in this setting. The submitted documentation includes no evidence of contraindications to these agents.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 36-year-old female who has been under the care of a neurologist who is a sleep medicine specialist for sleep-disordered breathing. The patient had a home trial of CPAP during the moth of September 2005 with good results. She has requested authorization for a CPAP device. The Health Plan has denied this request on the basis that a CPAP device is not medically necessary for treatment of the patients medical condition.Upon review of the submitted clinical information it appears the patient experiences problems during the day that are consistent with sleep-disordered breathing. The eight-day trial of a CPAP device in September 2005 gave positive clinical results. The patients neurologist is overseeing her care and feels there is a need for CPAP based on the entire clinical setting. Accordingly, I have determined the requested device is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned. The patient should receive a two-month trial of CPAP therapy. If during the two-month trial the patients symptoms are relieved, then CPAP therapy should be continued.
Appeal type: Medical Necessity
Decision: Overturned

A 23-year-old male enrollee has requested foot orthotics for treatment of his foot pain.  Findings:  The physician reviewer found that upon evaluation of the submitted documentation, the patient meets accepted clinical indications for the requested orthotics. Based upon the podiatry evaluation on the date indicated this patient underwent an extensive pedal evaluation and was found to have peroneus longus dysfunction syndrome of both feet with hypermobility of the first ray and instability of the medial longitudinal arch, joint pain to the navicular cuneiform joint, bursitis, neuritis, and neuralgia. These pathologies contribute to the patients foot pain and support the need for custom orthotics. The patient has achieved symptomatic relief with the use of orthotics in the past and is likely to continue to benefit from their use. Accordingly, the requested custom orthotics are medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

An 18-year-old male enrollee has requested biofeedback sessions for treatment of his chronic constipation. Findings:  The physician reviewer found that while the medial information submitted for review is sparse, there is technically adequate documentation to support biofeedback for management of what is likely a defecatory disorder in this patient. The patient does not appear by clinical criteria to have slow transit constipation and it is documented that the patient has not sustained anorectal trauma and does not have symptoms suspicious of neurological disease. It is documented that the patient takes adequate dietary fiber. Thus, there is no reason to expect that medications that increase colonic motility will result in improvement in his symptoms. Since the patients problem appears to be dysfunction in the initiation of a bowel movement he will likely respond to defecation training with biofeedback therapy.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 59-year-old woman with right-sided foot drop apparently as a complication of total hip replacement surgery in March 2005.  There is no documentation of upper extremity weakness in the record provided. The patient has difficulty maneuvering a standard wheelchair in the home and has requested a power wheelchair.  The Health Plan has denied the request based upon their determination that it is not medically necessary.The patient contends that she needs a power wheelchair because it is difficult to turn the standard wheelchair.  Generally, a manual wheelchair has the same turning radius as a power wheelchair, and in some cases the turning radius of the standard chair is tighter. The patient apparently has a severe right foot drop, but according to the records she has the ability to ambulate within the home for a distance of up to 70 feet with the AFO and a walker. It is anticipated that ambulation would improve with time and practice. There is no documentation of upper extremity weakness, which would preclude the use of a manual wheelchair.  Therefore, I have determined the requested equipment is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

A 63-year-old male enrollee has requested for artificial disc replacement surgery for treatment of his neck pain.  Findings:  Three physician reviewers found that there are no long-term, large, scientific studies showing the safety and effectiveness of cervical artificial disc replacement to date. Only small studies including the study reported by Mummaneni and colleagues, have demonstrated results in the short-term (less than two years follow-up). Moreover, the Food and Drug Administration (FDA) has required a seven- and ten-year study of each of the approved cervical disc replacement devices and these studies are currently ongoing.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for (1) hydroxychloroquine and (2) ivermectin treatment. There is a lack of support for the requested medications in this clinical setting. Studies report that available evidence does not support the use of hydroxychloroquine in the prevention or treatment of COVID-19. While Hosseini and colleagues note that ivermectin is of potential interest in the treatment of patients with mild and moderately severe COVID-19, there is insufficient clinical evidence on the efficacy and safety of this treatment. Given current medical literature, the requested medications are not medically indicated. Therefore, (1) hydroxychloroquine and (2) ivermectin treatment are not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested medications are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in infectious disease and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 58-year-old male enrollee has requested for Allegra 180mg for treatment of his prurigo nodularis. Findings:  The physician reviewer found that the documentation does not demonstrate that the patient has tried therapy with other preferred medications, including Doxepin, hydroxyzine or methotrexate. In addition, the medical literature supporting the use of Allegra for the treatment of prurigo nodularis is sparse, particularly at the doses suggested.  Treatment with intralesional steroids, thalidomide or other opioid antagonists has proven to be useful for treatment of this condition.  There is a lack of support in the medical literature for the use of Allegra 180mg, three times daily, in this clinical situation.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for lidocaine 5% patch. The submitted documentation does not support the medical necessity of the requested medication. Lidoderm 5% patches have been studied in randomized controlled trials, and it has not been found to be better than placebo. Thus, the medical evidence does not indicate that the requested medication is clinically effective for low back pain. There is a lack of support for the requested medication in this clinical setting. Therefore, lidocaine 5% patch is not medically necessary for treatment of this patient.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 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: Medical Necessity
Decision: Upheld

A 48-year-old male enrollee has requested revisional gastric bypass surgery for the treatment of his morbid obesity. Findings:  The physician reviewer found that there is no mechanical problem that would justify revisional surgery. Although the patients limb may have been short, this is not definitive and would not mandate the need for surgical revision.  Furthermore, as set forth above, UGI and EGD do not demonstrate pouch enlargement or fistula. The documentation provided demonstrates that the patients weight regain is most likely related to noncompliance. At this time there is no medical justification for the requested procedure. Although this patient may be an appropriate candidate for further surgery in the future, at this time revisional surgery is not medically justified.
Appeal type: Medical Necessity
Decision: Upheld

A 52-year-old female enrollee has requested foraminotomy for the treatment of her pain. Findings:  The physician reviewer found that there is no role for cervical foraminotomies for this patient who has the diagnosis of complex regional pain syndrome. The indications for cervical foraminotomies are relatively clear cut and they include soft disc herniation and significant foraminal encroachment by osteophytic spurs. This patient has neither. Surgical intervention is not indicated for this patient.
Appeal type: Experimental/Investigational
Decision: Overturned

A 54-year-old female enrollee has requested authorization and coverage for Botox injections for treatment of migraine headaches.Reviewers' Findings: Two of the three reviewing physicians found that patient has chronic daily headache in addition to migraine. Further trials of different preventive medications are not likely to offer further symptomatic relief. Botox has been demonstrated to be effective in treating chronic daily headache and migraine in double-blind placebo-controlled trials. Its use in this clinical setting is medically reasonable and appropriate and should be authorized.