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

The patient is a 57-year-old female with recurrent ventral hernia who has failed vertical banded gastroplasty. The patients body mass index (BMI) is 50. The submitted information indicates there was previous use of Marlex mesh for the patients hernia repair. The patients providers have recommended gastric bypass surgery with duodenal switch. The Health Plan has denied authorization and coverage for the requested procedure on the basis that it is considered investigational.There is now adequate data to demonstrate that duodenal switch is a more appropriate weight loss procedure for certain surgical revisions. Salvage from failed vertical banded gastroplasty involves conversion to Roux-en-Y gastric bypass or duodenal switch gastric bypass. In many cases, dense upper abdominal adhesions make conversion to Roux-en-Y gastric bypass untenable. Therefore, the duodenal switch is the medically indicated and necessary procedure for appropriate treatment of the patients condition. 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: Medical Necessity
Decision: Upheld

A 36-year-old male enrollee requested authorization and coverage of the medication xenical for the treatment of morbid obesity and hyperlipidemia.  The health plan denied the enrollees request indicating that the requested medication 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 medication is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

A 55-year-old female enrollee has requested Qualaquin for the treatment of her nocturnal leg cramps secondary to fibromyalgia. Findings:  The physician reviewer found that nocturnal leg cramps can be a very debilitating problem for many patients and Qualaquin has been long recognized as an effective means of controlling such cramps. Historically, Qualaquin was available as an over-the-counter medication for decades. However, in 1995 the Food and Drug Association (FDA) determined that Qualaquin should require a prescription and more recently, the FDA has indicated that Qualaquin is only appropriate for treating plasmodium falciparum malaria. The FDAs action was based on reports of serious adverse effects caused by Qualaquin administration for leg cramps.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested Harvoni for treatment of the enrollees hepatitis C virus. Findings: The physician reviewer found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with limited life expectancy due to nonliver-related conditions. The guidelines recommend that all patients should be treated, regardless of fibrosis stage. The guidelines recommend that treatment-naive genotype 1 patients should be treated with Harvoni for 12 weeks. These guideline recommendations are based on multiple randomized clinical trials, and the medication is U.S. Food and Drug Administration approved for all patients with chronic hepatitis C genotype 1 regardless of fibrosis stage (Kowdley, et al; Afdhal, et al). AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment (Jezequel, et al). For these reasons, the requested 12 week course of Harvoni 90-400 mg tablets is supported as medically necessary for the treatment of this patients hepatitis C infection.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 internal 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for vestibuloplasty and gingival graft to uncover previous implants and six (6) dental implants for treatment of his cherubism with excessive bone formation in the maxilla and mandible.  Findings:  The physician reviewer found that the records demonstrate that this patient has findings consistent with fibro-osseous disease with exuberant bone. In this clinical setting, the approach is to allow natural involution. However, when reduction or osseous contouring is required, re-expansion is a possibility. In this patients case, placement of dental implants was accomplished and is an option for the patient to restore his dentition while other options include fabrication of dentures. Given the lack of support for the requested procedures in this clinical setting, the requested vestibuloplasty and gingival graft to uncover previous implants and six (6) dental implants are not supported as medically necessary for treatment of this patients medical condition. The records demonstrate that this patient has findings consistent with fibro-osseous disease with exuberant bone. In this clinical setting, the approach is to allow natural involution. However, when reduction or osseous contouring is required, re-expansion is a possibility. In this patients case, placement of dental implants was accomplished and is an option for the patient to restore his dentition while other options include fabrication of dentures. Given the lack of support for the requested procedures in this clinical setting, the requested vestibuloplasty and gingival graft to uncover previous implants and six (6) dental implants are not supported as medically necessary for treatment of this 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 oral and maxillofacial 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

The patient is a five-year-old male with a history of allergies and asthma. He has had multiple ear infections resulting in insertion of bilateral PE tubes in March 2006. The patient has been receiving speech therapy for his articulation deficits with reported benefit. His therapist has recommended continued speech therapy twice a week for 12 weeks. The Health Plan has denied this request on the basis that additional speech therapy is not medically necessary for the patient.The patient has chronic asthma and recurrent otitis media with resultant articulation disorder. The submitted records document that he has had good response to tube insertion and speech therapy. His speech disorders are secondary to his physical illnesses. Speech therapy is the appropriate intervention for the patients speech deficit and should be continued. The patient should be provided the requested 12 weeks of speech therapy with re-evaluation by his provider at the end of the 12-week period to determine if additional therapy is needed.Based upon the information set forth above, I have determined the requested therapy is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

A 33-year-old male enrollee has requested minimally invasive, anterior approach, bilateral total hip arthroscopy using the HANA table for the treatment of his hip pain. Findings:  The physician reviewer found that the use of an anterior approach in this specific patient is likely to be beneficial, reducing the risk of dislocation and minimizing the surgical trauma to the tissues surrounding the hip joint. The approach chosen by the patients provider requires a meticulous and disciplined application of surgical technique. While it is possible to perform the planned procedure with a skilled assistant on a standard operating table, the use of the HANA table will provide easier access to the femoral shaft. The use of the anterior and anterolateral approaches allows for excellent visualization of the acetabulum, but requires special effort in visualizing and gaining access to the femoral shaft. By using special retractors as well as a specifically designed table, the difficulty created by the anterior approach can be overcome. The request for an anterior approach to bilateral total hip arthroscopy combined with the use of the HANA table is fully in the tradition of carefully developed surgical approaches and is medically appropriate and indicated for this patient.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a four-year-old male has requested past coverage for occupational therapy every other week and future occupational therapy every week for treatment of his delayed fine motor development.  Findings:  The physician reviewer found that occupational therapy is indicated when deficits exist in functional skills or occupational performance in the areas of play and leisure, self-maintenance, school tasks, or activities of daily living (Case-Smith and Arbesman). A systemic review by Polatajko and Cantin found that children with difficulty processing and integrating sensory information and difficulties with the performance of activities of daily living can benefit from intervention. However, no firm conclusions can be made regarding specific approaches due to the great variability in interventions and populations utilizing it. This patient has significant delays in fine motor and adaptive skills. Although sensory integration concerns are present, standard occupational therapy is medically necessary to help promote adaptive skill development, independence, and improve fine motor coordination (Volmar and Weisner). Based on the foregoing discussion, the occupational therapy at issue was and is medically necessary for treatment of this patients developmental delays.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Humalog 100 units/mL Kwikpen and Lantus 100 units/mL vials.  Findings:  The physician reviewer found that Humalog, Admelog is a lispro insulin that has been developed as a similar product to Humalog 100 units/mL. However, a patient can experience different results with the two medications. This patients records indicate that she tried Admelog with adverse or inconsistent results that have required medical attention. Thus, the Humalog 100 units/mL Kwikpen is supported as medically necessary for treatment of this patients diabetes. With regard to the request for Lantus vials, Basaglar is not recognized as interchangeable by the U.S. Food and Drug Administration (FDA). In addition, Dolinar and colleagues noted that Basaglar is not considered to be identical because it uses a different manufacturing process and excipients. Thus, it is not substitutable for Lantus. Given this patients concern for confusing her basal and meal insulin pens as she has in the past, it is reasonable to replace one pen with one vial medication. Having the meal insulin as a pen and the basal insulin as a vial, will avoid patient confusion of insulin and prevent a dangerous event that can lead to hypoglycemia. Accordingly, Lantus 100 units/mL vials and Humalog 100 units/mL Kwikpen are medically necessary for management of this patients diabetes.Final Result: The reviewer determined that the requested medications 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 internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism 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: Upheld

A 57-year-old male enrollee has requested for an endoscopic resection via retrosigmoid approach for treatment of her acoustic neuroma. Findings:  Two physician reviewers found that there is no available peer-reviewed literature supporting the superiority of the endoscopic retrosigmoid approach to acoustic neuroma resection. Recurrence rates of the minimal exposure technique are not addressed in the literature. Furthermore, there is no documentation that the endoscopic retrosigmoid approach to acoustic neuroma resection is likely to result in a better clinical outcome than other procedures. Nor is it within the standard of care in this setting.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a 16-year-old male enrollee has requested for ultrasound-assisted liposuction for breast gynecomastia for treatment of the enrollees bilateral gynecomastia.    Findings:  The physician reviewer found that there are no abnormalities found on physical exam including hepatic, renal, or thyroid        function and no documentation of evaluation of abnormalities of any serum profiles.  There are no biopsies, and no tissue diagnoses of gynecomastia. . There is no abnormal structure or abnormally functioning member due to congenital defects, developmental abnormalities, trauma, infection, tumors, or disease. No loss of functioning member is documented in the record.  The surgery was not performed to improve function or create a normal appearance to the extent possible.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting authorization and coverage for authorization and coverage for Humira, and if not then, Entyvio. The enrollee has diagnoses of Crohns disease with rectal bleeding, and pancreatic insufficiency. A progress note shows the enrollees current medications include Linzess, Creon, famotidine, metoclopramide, ondansetron, and pantoprazole. The enrollee started prednisone. A colonoscopy showed areas of moderately congested and ulcerated mucosa in the rectum and descending colon. A computed tomography scan of the abdomen was performed due to symptoms of weight loss and upper left quadrant pain, but records show no acute abdominal process was seen. The clinical guideline for the management of Crohns disease in adults from a professional society indicates, for mild to moderately severe disease, current options include Sulfasalazine and budesonide.  This enrollee has evidence of Crohns disease and appears to have had a good response to prednisone. A progress note reported the enrollee had normoactive bowel sounds, and no rebound, tenderness, or guarding was noted. No complaints were noted. Based on the records, the enrollee appears to have mild to moderate disease.  Biologic agents are advised for Crohns enrollees who are refractory to thiopurines or methotrexate, and have moderate to severe disease.  Humira and Entyvio are not medically necessary at this time, as the enrollee has not been tried on an immunomodulatory (medications used to normalize the immune system such as Azathioprine, Mercaptopurine or Methotrexate).Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for neuropsychological testing.Schroeder and colleagues state, A neuropsychological consultation can help characterize cognitive deficits, clarify diagnoses, and develop optimal management plans for patients with cognitive issues. The European Federation of Neurologic SocietiesEuropean Neurologic Society (EFNS-ENS) states that cognitive assessment has a key role in the diagnosis and management of dementia. Moreover, Schroeder and colleagues report, Neuropsychological testing is the preferred method for examining and documenting cognitive dysfunction. The authors conclude, Serial assessments can be useful for patients with mild cognitive impairment or in cases where the etiology of cognitive decline is unclear. A 12-month follow-up is often used to determine whether patterns of cognitive decline are consistent with a suspected etiology, identifying conversion of mild cognitive impairment to dementia, or to monitor the rate of cognitive change over time. In this case, the patient reports progressive memory difficulty for the last ten years. Based on the references above, neuropsychological testing is recommended to characterize cognitive deficits and clarify diagnoses. Serial assessments and follow-up testing are done in cases where the etiology of cognitive decline is unclear. Thus, investigating further with repeat neuropsychological testing is medically indicated. Therefore, the requested neuropsychological testing is medically necessary for the evaluation of the patients medical condition.Final Result: The reviewer determined that the requested service 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 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

A 64-year-old female enrollee has requested continuous glucose monitoring (CGM) system (Enlite sensor and the Medtronic 530 G system) for treatment of her type 2 diabetes.   Findings:  The physician reviewer found that review of the submitted documentation establishes the medical necessity of the requested services. The patient is having hypoglycemic readings and had previously been approved for CGM, but stopped it due to pain. The patient is testing 6 to 10 times per day and still has lows. In addition, she is on a pump using multiple boluses and still has lows.  Hence, a CGM that the patient can wear comfortably is medically indicated. Based on the documentation submitted for review and the peer-reviewed literature cited above, the requested services are medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Pathfinder TG system testing for evaluation of the enrollees possible pancreatic cancer. Findings:  The physician reviewers found that per the American Gastroenterological Association guidelines, the testing at issue is not listed as standard of care in the evaluation and management of cystic lesion of the pancreas. Therefore, the Pathfinder TG system testing was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: All three reviewers determined that the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewers number one, two, and three are board certified in internal medicine with sub-specialty certification in gastroenterology and 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

A 30-year-old female enrollee has requested for a power wheelchair for treatment of the enrollee, who is a tetraplegic. Findings:  The physician reviewer found that the records do not establish that her present wheelchair does not meet her functional needs or could not be repaired.It is not clearly documented that the back or seat could not be repaired/replaced to meet her seating needs.  It is also not clearly documented that the power tilt function on her present chair is not functioning or could not be repaired.  The published medical literature with respect to standing therapy in the setting of severe neurological disorders such as tetraplegia consists of preliminary studies with disparate and inconclusive results.  Despite subjective impressions of benefit, there is a lack of high-grade evidence to support the claims that the device will improve pulmonary function, improve circulation, improve bowel or bladder function, improve muscle function greater than conventional stretching, or reduce osteoporosis or fracture risk to a clinically significant degree.  There is no net benefit with respect to pressure ulcer prevention with use of the standing function beyond that which would be achieved with standard pressure relieving maneuvers on a power wheelchair using the power tilt-in-space function.  These additional features, moreover, add size and weight to the wheelchair which reduces maneuverability.