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

A 24-year-old male enrollee requested a continuous glucose monitoring system (E0784 insulin pump, A9277 transmitter, A9276 sensors, 530G with enlite) for medical treatment of his diabetes.  Findings:  Two physician reviewers found that this patient has poorly controlled diabetes, with HbA1c of 8.5% complicated by bipolar disorder. It is important that the patient controls his diabetes by bringing his glucose levels to a more acceptable range without increasing his risk of hypoglycemic coma. In this patient, the insulin dose is difficult to increase as needed because of risk of dangerous hypoglycemia. The CGM requested has the added feature of automatically suspending the delivery of insulin when hypoglycemia occurs, therefore limiting the time that the patient is in hypoglycemia. For these reasons, the system prescribed, (E0784 insulin pump, A9277 transmitter, A9276 sensors, 530G with Enlite) is more beneficial for this patient than any other standard therapy.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:   The parent of an enrollee has requested speech therapy for treatment of the enrollees speech delay.  The physician reviewer found that according to the literature, speech and language deficits that persist into the primary school years have long-term effects on literacy, socialization, and behavior.  In particular, speech sound disorder not only greatly reduces intelligibility, but has also been associated with later reading disability.  Speech sound disorders refer to any combination of difficulties that impact speech intelligibility, including perception, motor production, and phonological representation of speech sounds and segments.  Articulation disorders are those that impact the form of speech sounds and are associated with structural and motor-based problems. Phonology disorders impact the way speech sounds function within a language.  The treatment approaches have traditionally focused on either articulation or phonology.  The literature supports speech therapy intervention in this clinical setting.  This patient has made significant progress with intervention, but has not yet achieved age appropriate articulation skills.  All told, speech therapy is medically indicated for the treatment of this patient. Final Result: The reviewer determined that the services at issue were and 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 pediatrics with sub-specialty 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

The patients parent has requested authorization and coverage for food allergy desensitization/tolerance induction program services and prospective authorization and coverage for 15 additional future dates of service for the food allergy desensitization/tolerance induction program services. While oral food desensitization has been achieved in the majority of patients in randomized controlled studies, few patients have been found to develop sustained tolerance in the long-term. Moreover, proceeding with oral desensitization to a multitude of foods to which there is no history of anaphylaxis is not supported in the current medical literature. It is within the standard of care to measure immunoglobulin E (IgE) levels to specific foods for a patient. However, an extensive array of blood tests examining foods to which a patient has not experienced a reaction has not been demonstrated to improve patient health outcomes in this clinical setting. All told, the requested food allergy desensitization/tolerance induction program services and prospective authorization and coverage for 15 additional future dates of service for the food allergy desensitization/tolerance induction program services are not medically necessary for treatment of this patient.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 internal medicine with subspecialty certification in allergy and immunology 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the digital breast tomosynthesis for evaluation of the enrollees risk for breast cancer. Findings:  Two physician reviewers found that tomosynthesis is a technique that was developed several years ago as a problem solving adjunct to routine mammography. Applying the same basic concept as computed tomography (CT) scanning, by separating the various layers of breast tissue, one can better detect abnormalities. However, in this particular patient, there were no problems to be resolved since the patient does not have dense breasts, she did not have a mass, there were no palpable lumps, and she did not have suspicious calcifications. In this setting, a routine mammogram would have been sufficient. Tomosynthesis has not been shown to provide significant increased value in patients who do not have dense tissue that could obscure an abnormality, especially when there has been no change when compared to multiple prior mammograms. Thus, in this clinical setting, the use of the digital breast tomosynthesis performed was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: The reviewers determined that the service 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: All three reviewers are board certified in diagnostic radiology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a 5-month-old female enrollee has requested anorectovaginoplasty and urethroplasty for treatment of the enrollees congenital adrenal hyperplasia.  Findings:  The physician reviewer found that the question of whether the recommended procedures are appropriate care cannot be answered definitively until the remainder of the diagnostic workup reveals the level of the confluence of the urethra and vagina as well as the adequacy of the vaginal canal. The lack of vaginal obstruction eliminates any time pressure on the surgery to improve the vaginal introitus and elongation of the urethra. Additionally, the proposed procedures can be performed after the age of six months without any deficit in outcome. The Health Plan indicates surgery can be arranged once the patient is evaluated and further workup (genitogram) is obtained. The recommendation of the Health Plan is consistent with medically reasonable and appropriate care of the patients CAH related anomaly. For the reasons set forth above, the requested services are not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for bilateral Supartz injections of both knees. Findings:  The physician reviewer found that medical literature, although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. The current evidence is limited, and guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate that the evidence is not conclusive. In light of the foregoing, viscosupplementation can only be recommended in individuals with a history of lasting benefit from prior injections, and in carefully selected cases where everything else has been tried, and the options are limited. In this case, the patient has tried and failed other conservative treatments, including physical therapy, a home exercise program, medications, and cortisone injections without significant lasting benefit, with the alternative being a total knee arthroplasty. Given the patients limited options and based on the current medical literature, the requested services are medically indicated. Therefore, bilateral Supartz injections of both knees are medically necessary for the treatment of this patient.Final Result: The reviewer 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 orthopedic 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

A 41-year-old female enrollee has requested care for the treatment of her condition. Findings:  The physician reviewer found that the Health Plans denial of past and further care at the facility is correct and the request is not medically necessary. Based on the occupational therapy notes, the patient could and should able to do her (ADLs) activities of daily living at home without assistance. She is not requiring skilled nursing services that would warrant further inpatient care. In her case, the home physical therapy would be comparable to physical therapy services on an inpatient basis. Further inpatient care would be custodial and not medically necessary. She should be granted home physical therapy on an outpatient basis after removal of her non-weight bearing status and cast.
Appeal type: Medical Necessity
Decision: Upheld

The parent of an 11-year-old enrollee has requested Nutropin AQ for treatment of the enrollees precocious puberty. Findings:  The physician reviewer found that the patients mid-parental target height is 62.5. A bone age at age 10 years 7 months was read at 12 years when she began menses. Her height was 55 at this time. This should approximate to a predicted adult height of 61 from the advanced table of the Greulich and Pyle Hand Atlas, albeit this might admittedly prove somewhat optimistic. At this late stage in her development, the addition of growth hormone therapy to Depot Lupron therapy is judged unlikely to contribute significantly to her normal predicted adult height. The use of growth hormone therapy in precocious puberty is generally not supported in the literature. Nutropin AQ is not medically indicated for treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for myocardial strain imaging using speckle tracking-derived assessment of myocardial mechanics (CPT 93356) provided by M.D. The American College of Cardiology guidelines on the appropriate indications for myocardial strain imaging include patients prior to and following exposure to potentially cardiotoxic agents or for patients with suspected hypertrophic cardiomyopathy. In this case, the records do not reflect that the patient meets either of these indications. Therefore, myocardial strain imaging using speckle tracking-derived assessment of myocardial mechanics (CPT 93356) provided by M.D., was not likely to have been more beneficial for evaluation of the patients condition than any available standard therapy.Findings:  Three of the three physician reviewers found the myocardial strain imaging using speckle tracking-derived assessment of myocardial mechanics (CPT 93356) provided M.D., at issue was not likely to have been more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the service at issue was not likely to have been 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 1 and 3 are internal medicine with sub-specialty certification in cardiovascular disease and are actively practicing. Physician reviewer is board certified in internal medicine with sub-specialty certifications in cardiovascular disease and in clinical cardiac electrophysiology and is 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 48-year-old male enrollee requested authorization and coverage of left ankle surgery. The Health Plan denied the request indicating that the requested procedure is not medically necessary for the treatment of the enrollees ankle pain.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: Medical Necessity
Decision: Upheld

The patient is a 46-year-old woman who has requested authorization and coverage for fat grafting of an abdominal defect. In May 2003, the patients provider noted the patient had a left anterior abdominal wall budge that was 4x3cm along the left vertical incision line. Mild tenderness was noted but there was no infection, erythema, or hernia. In August 2003, the patient underwent abdominal scar excision over 13cm in length with adjacent tissue transfer reconstruction. The submitted photographs reveal a generalized abdominal bulge consistent with excess weight rather than a localized bulge and depressed scar. The Health Plan has denied authorization and coverage for fat grafting surgery on the basis that it is not medically necessary.Review of the submitted evidence indicates that fat grafting surgery is not medically necessary. The submitted evidence reveals no functional deformity. In addition, evidence of conservative treatment with weight loss has not been provided. Furthermore, the patient has already undergone scar revision surgery. Thus, the requested procedure is likely to provide only limited improvement. Therefore, I have determined that the requested procedure is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

A 64-year-old male enrollee has requested for a mobile scooter (electric) for treatment of his medical condition. Findings:  The physician reviewer found that Medicare guidelines state a power mobility device may be covered for a patient with a personal mobility deficit that significantly impairs participation in mobility-related activities of daily living (such as toileting, feeding, dressing, grooming, and bathing) in customary locations within the home, provided the patient's condition is not ameliorable by a walker, cane or manual wheelchair. In this particular case, this patients condition is ameliorable by a type of walker (a rollator). If there is concern of the patient falling while attempting ambulation, then a manual wheelchair may be appropriate.
Appeal type: Medical Necessity
Decision: Upheld

A 47-year-old female enrollee has requested residential eating disorder level of care for treatment of her eating disorder.  Findings:  The physician reviewer found that based on review of the available records, the patient has a history of anorexia for most of her adult life precipitated by abuse in her family. She started losing weight in early 2011, this represents greater than 90% of her IBW. In addition, the records do not document any acute medical problems such as electrolyte or fluid imbalance, nor did she have hypotension or cardiovascular problems. Therefore, according to the American Psychiatric Association (APA) treatment guidelines, this patient can be safely and adequately be managed on an outpatient basis as the medical necessity of the requested residential treatment program services has not been established.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:   An enrollee has requested iStent surgery for treatment of her glaucoma. Three physician reviewers found that in the peer-reviewed medical literature, Wellik and Dale demonstrated that the micro-bypass stent is a relatively safe procedure, with limited complications and no serious adverse sequelae. Samuelson and colleagues reported that pressure reduction on fewer medications was clinically and statistically significantly better one year after iStent with cataract surgery versus cataract surgery alone, with an overall safety profile similar to that of cataract surgery alone. Craven and colleagues found that patients with combined single trabecular micro-bypass stent and cataract surgery had significantly better intraocular pressure control on no medication through two years when compared to patients who underwent cataract surgery alone. All told, the data indicates the iStent surgery was likely to have been more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: Three reviewers determined that the services at issue were 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: All three reviewers are board certified in ophthalmology 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: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested Harvoni for 12 weeks for treatment of her hepatitis C virus.  Findings: The reviewer found that according to the 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 non-liver-related conditions. The guidelines recommend that treatment-naive genotype 1a 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 (FDA)-approved for all patients with chronic hepatitis C genotype 1 regardless of fibrosis stage AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, Harvoni for 12 weeks is 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 with sub-specialty certification 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 a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for genetic testing. This patient presents with a personal history of breast cancer and an extensive family history of cancer on the maternal side. The patient was evaluated by a genetic counselor and found to have an increased risk of an inheritable mutation. In addition, the patient meets the National Comprehensive Cancer Network (NCCN) guidelines for testing. In the medical literature, researchers reported on a retrospective analysis of 337 patients who met the NCCN criteria for BRCA1 and BRCA2 mutation testing and showed that 25 patients had non-BRCA mutations on genetic testing. Moreover, the largest studies reporting on the outcomes of multigene testing indicate that among women tested in clinical settings, about 5-10% have a BRCA1 or BRCA2 mutation, and about 4-7% have a harmful mutation in another gene associated with high to moderate risks of breast and/or ovarian cancer, or a mutation in a newer gene that may also be associated with increased risks for these cancers. Panel testing is now considered a standard of care in this clinical setting. Accordingly, the genetic testing rendered was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.One reviewer found that the genetic testing rendered was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: Two of the 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:  One reviewer is board certified in internal medicine with sub-specialty certification in medical oncology and is actively practicing. One Reviewer is board certified in internal medicine with sub-specialty certification in medical oncology and is actively practicing.  One Reviewer is board certified in internal medicine with sub-specialty certification in medical oncology and is 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.