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

The parent of an 8-year-old male enrollee has requested coverage for Applied Behavioral Analysis (ABA) therapy for treatment of the enrollees autism. Findings:  The physician reviewer found that the patient has significant cognitive delays, deals with minimal frustration with tantrums and screaming and is a danger to himself, as he frequently runs away. The patient has participated in ABA therapy for at least the past two years and he has since achieved very slow, but definite behavioral improvements. Despite the patients slow improvement in response to ABA therapy, ABA therapy remains the standard of care for the treatment of autism.  The medical literature strongly supports the treatment of autism with ABA therapy. ABA therapy has a 40-year record of substantially improving motor, verbal and social interactive skills in autistic children and autistic children who received ABA therapy have demonstrated significantly improved behavioral outcomes as compared to autistic children who did not receive ABA therapy (Myers, et al.). Additionally, ABA therapy has been proven to be effective in multiple controlled studies. This patient has been diagnosed with autism and ABA therapy remains the documented therapy of choice. However, there is limited evidence regarding the age at which ABA therapy should be discontinued. Generally, ABA therapy is slowly tapered beginning at the age of eight. The recommendation by the patients provider for 1.5 hours daily of ABA therapy is medically appropriate for this patient, as are the recommended supervision and parental guidance sessions, with a cumulative total of 35 hours of ABA therapy per month. As such, the Health Plans denial should be partially overturned.
Appeal type: Medical Necessity
Decision: Overturned

A 33-year-old male enrollee requested the prescription medication Pentasa for medical treatment of his Crohns disease.  Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested medication in this patients case.  Apriso ER has been offered as a first-line therapy , however, in this patients case, Apriso ER is an inappropriate alternative.  Since this patient has ileal disease, he requires a mesalamine product which will deliver 5-aminosalicylic acid (5-ASA) to the entire ileal mucosa.  Per the current medical evidence, this can be achieved by Pentasa due to its unique drug delivery.  In contrast, the formulary alternative will only deliver mesalamine to the colonic mucosa, which will be not be of benefit in this clinical setting.  All told, Pentasa is medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

A 52-year-old male enrollee has requested skilled nursing facility (SNF) services including physical therapy and occupational therapy for treatment of his left-sided paralysis due to history of tumor.  Findings:  The physician reviewer found that the patient has chronic paralysis not from stroke but from neurological injury. However, the neurological response in rehabilitation parallels that of stroke. Physical therapy and occupational therapy do not improve neurological function but improve function at a given neurological state. When neurological status is stable, further recovery with formal rehabilitation services cannot be expected. The records indicate that this patient has chronic fixed neurological deficit and has reached maximal recovery. Continued daily therapy will not produce significant changes. The patient has reached a level of function that is not expected to respond to daily skilled therapy to restore or maintain function. Moreover, the patient has no daily skilled nursing needs. All told, the SNF services including physical therapy and occupational therapy are not supported as medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for orthotics for treatment of the enrollees foot pain. Findings:  The physician reviewer found that review of the submitted documentation and relevant literature demonstrates the medical necessity of orthotics. In this case, the patient has collapsed arch, pain upon ambulation, neuropathy, a significant hypermobility syndrome and Ehlers-Danlos syndrome. Custom orthotics have been demonstrated to be effective in the treatment of the above mentioned pathologies. Custom orthotics are firm functional devices that support both the medial arch as well as the midtarsal arch, and will reduce hypermobility, support the foot and slow if not halt further progression of patients foot deformity. Reducing hypermobility in the foot will likely help alleviate the patients foot pain. As such, the request for orthotics is medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the requested equipment 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 podiatry 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 59-year-old male enrollee has requested for laparoscopic biliopancreatic diversion with duodenal switch for treatment of his morbid obesity. Findings:  The physician reviewer found that there is no scientific evidence which supports the position that patients who have a BMI of less than 50 and have undergone the duodenal switch procedure have done worse than those patients who had a BMI of greater than 50.With the duodenal switch procedure, common and alimentary channel lengths can be tailored for each patient, which in fact makes the procedure more versatile, allowing for greater use of the procedure in a variety of patients.
Appeal type: Experimental/Investigational
Decision: Upheld

A 61-year-old female enrollee has requested reimbursement for collagen cross links/bone turnover markers testing for evaluation of the enrollees osteoporosis.  Findings:  Three physician reviewers found that the patient has a history of low bone mineral density.  The medical records noted that the patient had been menopausal for 10 years.  The patient did not have a history of bone fracture or kidney stones.  The providers assessment was osteoporosis.  She has requested reimbursement for collagen cross links/bone turnover markers testing.  In this patients case, the testing at issue was not likely to be of greater benefit than other methods of evaluation.  She had an established diagnosis of osteoporosis per a bone density study.  Bone turnover markers testing was not likely to be of benefit in this clinical setting.  At this time, there is no consensus on whether there is a role for the testing at issue in determining candidates for osteoporosis therapy.  The decision regarding the appropriate candidates for osteoporosis therapy should be based upon fracture risk assessment using bone mineral density and clinical risk factors.  Thus, the superior efficacy of collagen cross links/bone turnover markers testing has not been established.
Appeal type: Experimental/Investigational
Decision: Upheld

A 39-year-old female enrollee has requested reimbursement and prospective authorization and coverage for photo light therapy already received and forward for treatment of the enrollees palmar dermatitis.  Findings:  Two physician reviewers found that the patient is a 39-year-old female with chronic bilateral palmar dermatitis that had improved due to treatment with narrow band UVB (UVBNB). The patient has requested reimbursement and prospective authorization and coverage for UVBNB therapy already received and going forward. The Health Plan has denied this request indicating that this therapy was and is considered investigational for treatment of the patients skin disease. Per the Health Plan, available medical studies do not show that this service improves health outcomes, is as good as or better than standard alternatives, or shows improvement outside the research setting. Although potentially therapeutically effective in atopic dermatitis, UVBNB is not considered a first-line treatment. The standard of care includes high potency topical corticosteroids. If palmar dermatitis is in fact palmar psoriasis, other standard psoriasis treatment modalities should be considered as well. The suggested course of action is to finalize the diagnosis based on the biopsy and then choose the first-line treatment for the patients skin condition established by the clinical and pathological correlation. For palmar psoriasis, if other therapies fail, then UVBNB may be considered to be more beneficial.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a seven-year-old male enrollee has requested continuation of growth hormone (Genotropin) for the treatment of the enrollees growth hormone deficiency. Findings:  The physician reviewer found that the submitted evidence indicates that the patient has responded well to the preparation. Synthetic GH therapy made by a variety of manufacturers appears to be equally effective and without differential immunogenicities. However, immunogenicity has been problematic in certain developmental GH preparations and therefore it is not advisable to switch biological products at this point.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patients parent has requested reimbursement for DOC Band cranial remolding orthotic device. As noted in the records provided for review, this patient has a cranial vault asymmetry index (CVAI) of 6.2, cephalic index of 89.5, and a cranial vault asymmetry of 8 mm. Per the Plagiocephaly Severity Scale of the Childrens Hospital of Atlanta, the patients CVAI of 6.2 places him in the stage 2, mild range. The authors report that a CVAI of 3.5-6.25 with minimal asymmetry in one posterior quadrant and no secondary changes should be treated with a repositioning program. This patient is described as having right occipital flattening, left frontal flattening, anterior ear shift right, anterior orbital shift right and eye fissure narrowing left. This presentation includes some overlap with stage 3, moderate plagiocephaly. However, his CVAI is in the mild range rather than moderate, stage 3 range. Researchers found a lack of data demonstrating a causal connection between positional plagiocephaly and lower cognitive scores in school-aged patients to support an indication for treatment with a cranial remolding orthotic. All told, the DOC Band cranial remolding orthotic device was not medically necessary for treatment of this patient.Final Result: The reviewer determined that the device at issue was 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 neurology with special qualification in child neurology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for hydrocodone-acetaminophen 10-325 mg, four pills per day at 120 pills for a 30-day supply. The Health Plan has denied this request indicating that the requested medication quantity is not medically necessary for treatment of the patients chronic pain. The submitted documentation does not support the medical necessity of the requested medication quantity. The Centers for Disease Control guidelines do not support the chronic use of opiates for non-malignant disease. There is no documentation of hormonal therapy or of surgical intervention for this patients pain. The dosage of gabapentin is sub-therapeutic. The current guidelines do not support the use of chronic opiate therapy for endometriosis. Therefore, hydrocodone-acetaminophen 10-325 mg, four pills per day at 120 pills for a 30-day supply is not medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested medication quantity 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a consultation with a cardiothoracic surgeon. Findings:  The physician reviewer found that the requested consultation with a cardiothoracic surgeon has been established as medically necessary for evaluation of the patients medical condition. Mild cases of palmar hyperhidrosis can be managed medically without surgery by using topical aluminum chloride, oral anticholinergic agents, or iontophoresis. These treatments are only effective in patients with mild hyperhidrosis. In this case, the patient presents with severe hyperhidrosis. She has been treated with Botox injections to the hands which provided temporary relief and was painful. She also developed hand weakness after treatment with Botox. Thus, the standard medical treatments would not be expected to have any significant long-term benefit for this patient with serious severe palmar hyperhidrosis. Her provider recommends treatment with ETS, which is considered a first-line treatment in appropriate patients. Final Result: The reviewer determined that the requested consultation is medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in thoracic 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: Upheld

Nature of Statutory Criteria/ Case Summary:  The enrollee has requested coverage for residential treatment services that was denied by the health plan as not medically necessary. The records indicate this enrollee was admitted for inpatient mental health residential treatment due to worsened depressive symptoms and alcohol use.  He had depressed mood, suicidal ideation with a plan to overdose, feelings of hopelessness, helplessness and decreased energy. He relapsed prior to admission after reporting being sober for one year. Past medical history included delirium tremens and a past psychiatric hospitalization.  Medications included Lexapro and Campral.  He had diagnoses of Major Depressive Disorder and Alcohol Use Disorder.  While admitted, he was placed on self-harm and suicide precautions, received a medication evaluation, as well as individual and group therapy. Medical guidelines indicate that patients should be treated in the least restrictive setting that is most likely to prove to be safe and effective and that patients with suicidal plans, intent, behaviors or inability to adequately care for basic needs are in need of inpatient treatment. The estimated degree of risk to self and to others is a significant factor in determining treatment setting. In this case, on the days in question, there were no reports of suicidal or homicidal ideations, plan or intent, self-injurious, aggressive or agitated behavior, psychotic symptoms, inability to adequately care for self, medical instability or substance use. The patients mood had improved and there were no reports of severe depressive symptoms or manic episodes.  There were also no reports of identifiable or quantifiable treatment goals or objectives that could only be achieved in a 24 hour mental health residential setting or that could not be achieved in a less restrictive setting. Final Result: The reviewer determined that the requested service is not medically necessary for thetreatment of the enrollees medical condition. Therefore, the health plans denial should be upheld. Credentials/Qualifications: The physician reviewer is board certified in 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 41-year-old female enrollee requested authorization and coverage of a referral to an endocrinologist. The Health Plan has denied the request indicating that the requested referral is not medically necessary for treatment of the enrollees multinodular goiter.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested referral is not medically necessary.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:   An enrollee has requested breast tomosynthesis for evaluation of her medical condition. Two physician reviewers found that breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than available standard modalities. In this case, the patient presented for a breast cancer screening with tomosynthesis. The study by Skaane and colleagues concluded that The use of mammography plus tomosynthesis in a screening environment resulted in a significantly higher cancer detection rate and enabled the detection of more invasive cancers. Based on the medical literature cited above, there is support for the use of breast tomosynthesis over conventional mammogram due to improved cancer detection rate.  Final Result:  Two reviewers determined that the diagnostic procedure at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: All three reviewers are board certified in diagnostic radiology and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

A 52-year-old female enrollee has requested cervical nerve block injections with fluoroscopy/x-ray guidance for treatment of her cervical spondylosis with degenerative disc disease.  Findings:  Three physician reviewers found that based on the patients records and the peer reviewed medical literature, epidural injections are clinically indicated and likely to be superior to any alternative treatment for this patient at this time. The patient has specifically requested nerve blocks as she had in the past and the records indicate that she was previously treated with cervical epidural injections. Since the patients clinical findings are more consistent with radiculopathy than facet joint pain, epidural injections are likely to provide this patient with relief of her symptoms and should therefore be approved.
Appeal type: Medical Necessity
Decision: Overturned

A 57-year-old female enrollee requested stem cell fat grafting to the right breast for medical treatment of the enrollees medical condition status post partial mastectomy and radiation therapy.   Findings:  The physician reviewer found that the records indicate that this patients degree of deformity as demonstrated on examination and visualized in photographs should be considered abnormal. In addition, this abnormal condition is the result of treatment for breast cancer. The patients condition and treatment including partial mastectomy and postoperative radiation therapy created an abnormal breast from the tissue removal and changes associated with radiation therapy. Stem cell fat grafting is likely to result in a more than a minimal improvement in the patients appearance. Thus, the requested stem cell fat grafting is supported as reconstructive in nature for treatment of this patients contour deformity of the right breast.
Appeal type: Medical Necessity
Decision: Upheld

A 53-year-old female enrollee requested excessive skin removal for medical treatment of the enrollees excess skin.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  Removal of excess skin would be medically necessary rather than cosmetic in nature if the removed skin has a history of recurrent infections or rashes, is necrotic, or interferes with range of motion.  The presence of a pannus alone does not make its removal medically necessary.  In this case, the notes indicate moderate groin and pannus intertrigo.  However, the submitted photographs do not show a hanging pannus.  In the absence of such a pannus, it is not clear that removing skin will treat her rash.  The medical records do not support the medical necessity of a panniculectomy, thigh lift/thighplasty or brachioplasty.  Per the reviewed photographs, this patients condition does not constitute an abnormal structure of the body. The requested surgery is not being performed to improve function or create a normal appearance from an abnormal one.  All told, the requested excessive skin removal is not reconstructive in nature and is not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

A 38-year-old female enrollee has requested Humira for treatment of her inflammatory arthritis.  Findings:  The physician reviewer found that Humira is approved for the treatment of Crohns disease and by report, such treatment is  recommended by the patients gastroenterologist due to continuing bowel disease. The patient still has a colostomy and her history makes it clear that her disease is severe, recurrent and damaging. The patient has required multiple surgeries, making inadequate control an unacceptable risk. In addition, it is the opinion of the treating rheumatologist that the associated joint symptoms are also severe, and to a significant degree, part of the patients Crohns disease. A trial of Humira is appropriate for control of the patients bowel disease. This agent will hopefully allow reversal of the patients colostomy, decrease the risk of an exacerbation and control her arthropathy.