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

A 64-year-old female enrollee has requested Botox injections for treatment of her hyperhidrosis and history of Hailey-Hailey disease. Findings:  Two physician reviewers found that hyperhidrosis is excessive sweating beyond that required to return body temperature to normal. It can be localized or generalized, commonly affecting the groin, axillae, palms, soles or face, and can have a substantial negative effect on a patients quality of life (Coutinho dos Santos, et al). Hailey-Hailey disease is a rare disease that presents clinically with recurrent flares of erosions and vesicles that mainly affect the skin folds, including groin. Hyperhidrosis is one of the factors that can trigger or aggravate a flare-up, and its treatment is important for controlling the disease and preventing further episodes. Hailey-Hailey disease has been successfully treated with injections of Botulinum toxin type A that inhibits sweating (Feily, et al). Treatment of this patient with Botox has been shown to provide for stable remission for about six months, indicating that it has been more effective than other treatment methods. The therapeutic effect stems from inhibition of sweating, which, in turn, alleviates symptoms associated with Hailey-Hailey disease. Standard topical treatments of inguinal hyperhidrosis in this patient are contraindicated, because these drugs can aggravate Hailey-Hailey disease. For these reasons, the requested Botox injections in the inguinal area are supported as likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for digital breast tomosynthesis for evaluation of the enrollees medical condition. Findings:  Three physician reviewers found that there is sufficient support for the services at issue in this clinical setting.  Breast tomosynthesis provides advantages to radiologists interpreting mammograms, especially in women with extremely or heterogeneously dense tissue, such as the patient under review.  This tomographic method often allows the reader to separate dense glandular elements from underlying mass/architectural distortion, resulting in a decrease in biopsies and callbacks and increase in detection of small cancers compared to two-dimensional imaging alone. Final Result: Three reviewers determined that the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: All three physician reviewers are board certified in 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 patient is a 40-year-old male with a reported history of diabetes, neuropathy, congestive heart failure, degenerative joint disease of the lumbar spine, asthma, sleep apnea and lower extremity edema. His cardiologist has recommended a power-operated vehicle (POV). The Health Plan has denied coverage for the requested POV on the basis that it is not medically necessary. The submitted clinical information does not support the medical necessity of a POV at this time. The patients cardiologist requested the POV for severe neuropathy rather than a cardiac condition. Furthermore, the cardiology notes do not objectively document an exam assessing the degree of neuropathy. In contrast, the physiatrist evaluation states sensation is intact and documents the patient walking into the exam room with a four-wheeled walker with normal blood pressure and respirations. The physiatrist states further information would be required such as an EMG to verify the need for a POV. Moreover, there is no documentation of the severity of the patients osteoarthritis or report of orthopedic exam findings. Hence, there is no objective evidence supporting the need for a POV.For the reasons stated above, I have determined the requested POV is not medically necessary the patients mobility. The Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Aliqopa infusions.Findings:  Three physician reviewers found that this patient was diagnosed with stage IV gastrointestinal stromal tumor. He has been treated with several prior lines of therapy, including imatinib, sunitinib, and Temodar. Aliqopa is not supported by the National Comprehensive Cancer Network guidelines in this clinical setting. The current medical literature does not support the use of this drug for gastrointestinal stromal tumor outside of a clinical trial. There is a lack of evidence indicating that the requested medication is likely to be more effective than standard therapies, such as regorafenib. Therefore, the requested Aliqopa infusions are not likely to be superior over other treatment options. Final Result: The reviewers determined that the requested medication is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in medical oncology 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for perinatology follow-up visit, ultrasound, and Doppler velocimetry testing for the evaluation and treatment of the enrollees pregnancy.  Findings:  The physician reviewer found that the general recommendations for ultrasound in pregnancy include a dating ultrasound in the first trimester and/or an ultrasound for nuchal translucency if the patient requests genetic testing. In the second trimester, all patients should receive an anatomy scan.  Follow-up ultrasounds in addition to those are recommended based on maternal medical history or abnormal fetal findings. In this case, the records support the requested ultrasound. However, the records do not document an indication for Doppler velocimetry testing in this case, such as fetal anemia or growth restriction. Additionally, the requested perinatology follow-up is not indicated at this time. A perinatology follow-up may be needed if there were a new high-risk abnormality found. In sum, the requested ultrasound is medically necessary for the evaluation and treatment of this patient. However, the submitted records fail to demonstrate the medical necessity of the requested perinatology follow-up visit or Doppler velocimetry testing. Final Result: The reviewer determined that a portion of the requested services is medically necessary for evaluation and treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned. Credentials/Qualifications: The reviewer is board certified in obstetrics and gynecology 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 25-year-old female has requested gastric bypass (Roux-en-Y) surgery for treatment of her morbid obesity.  Findings:  The physician reviewer found that this patient meets all standard nationally accepted guidelines for bariatric surgery including the National Institutes for Health (NIH) Consensus Guidelines. The patient is over 18 years of age, has failed dietary efforts with a BMI of at least 40 and has documentation of a thorough multidisciplinary evaluation that did not reveal any obvious medical, dietary, behavioral or metabolic barriers to surgery. Therefore, standard medical necessity criteria are met. There is no available published literature that documents any outcomes benefit from pre-surgical consecutive months of weight loss over failed weight loss efforts. In addition, a pre-determined length of mandated weight loss has not been determined to have any outcomes benefits.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested vein treatment (radiofrequency ablation, right leg). Findings:  The physician reviewer found that there is sufficient support in the documentation provided for the requested procedure in this clinical setting. The treating provider reported that he performed an ultrasound on the right leg and that the vein is a good target for ablation. The saphenofemoral junction measures at 1.2 cm and the saphenous vein measures at 0.8 and 0.9 cm further down the leg. The patient has failed conservative treatment options and noted that her pain interferes with activities of daily living. Moreover, the medical literature supports the efficacy of this therapy for treatment of the patients medical condition. Final Result: The reviewer determined that the requested procedure 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 vascular surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: A review of the records indicates that the enrollee was admitted to a partial hospitalization program. After an initial period of authorized services, the Health Plan indicated that, the enrollee did not require more intensive evaluation and treatment than from a lower level of care. The submitted documentation does not support the medical necessity of partial hospitalization program. The patient was not in severe withdrawals. She had moderate cravings for THC and reported moderate fatigue. She denied suicidal or homicidal ideation. There were no emotional, behavioral, cognitive, or impulsive barriers to stepping down to a lower level of care at that point, as she did not require frequent medical and nursing supervision. The patient was medically and psychiatrically stable, and she was medication compliant. The patient was highly motivated, actively participating, and residing in a sober living environment which she experienced as not stressful. All of these factors lessened her chances of relapse. She had support at home. There was no evidence that stepping down to a lower level of care would lead to deterioration in the patients clinical status. Under these circumstances, partial hospitalization program services provided were not medically necessary for treatment of the patients behavioral health conditions.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 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

A 22-year-old female enrollee has requested for chemical dependency residential treatment services for treatment of the her amphetamine dependency. Findings:  The physician reviewer found that while this patient was in residential treatment she was not suicidal, homicidal or psychotic. In addition, she was medically stable. the patient did not meet nationally accepted medical necessity criteria (ASAM) for residential treatment services.
Appeal type: Medical Necessity
Decision: Upheld

A 48-year-old female enrollee requested authorization and coverage of a bilateral labiaplasty. The Health Plan denied the request indicating that the requested procedure is cosmetic in nature and not medically necessary for treatment of the enrollees enlarged minor labia.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 cosmetic in nature and not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:e enrollee has requested authorization and coverage for rituximab injection 100 mg for treatment of the enrollees autonomic neuropathy associated with anti-acetylcholine receptor antibody with gastric dysmotility. Findings:  The physician reviewer found that Dysmotility disorders can be caused by multiple causes. In this case, the patients dysmotility is caused by anti-acetylcholine receptor antibody. In such cases the use of an autoimmune treatment is supported as beneficial in the medical literature. In anti-Hu paraneoplastic syndromes, therapy of the underlying tumour remains the mainstay. Where there is no tumour found, immunologically based therapies such as rituximab can be effective in anti-Hu paraneoplastic syndrome with gastrointestinal dysmotility. As such, the patient is likely to benefit from the proposed therapy. Therefore, the request for rituximab injection 100 mg has been established as medically necessary for treatment of the patients medical condition. 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 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

The parent of a one-year-old female enrollee has requested physical therapy services for treatment of the enrollees Down syndrome. Findings:  The physician reviewer found that in this patients case, the requested physical therapy services are medically indicated.  As noted by Weijerman and De Winter, children with Down syndrome often have ligamentous laxity, joint hypermobility and hypotonia presenting in a variety of ways. The authors reported that delays in motor development appear to be particularly related to the degree of hypotonia, which negatively influences development and leads to problems in postural control and to typically static and symmetrical movement patterns, compensatory movement strategies, and lack of movement variability.  The authors noted that physical therapy supports the development of the basic gross motor skills in children with Down syndrome.  This patient has gross motor delays in both stationary and locomotion skills, with challenges in standing, cruising, and walking. Physical therapy is ideally suited to address her deficits in gross motor development.  This patient has made gains when offered physical therapy services in the past, demonstrating ability to achieve new skills. All told, the requested physical therapy services are medically necessary to optimize her functional gains in gross motor skills.
Appeal type: Medical Necessity
Decision: Upheld

A 61-year-old male enrollee requested a power wheelchair for medical treatment of his medical condition.  Findings:  The physician reviewer found that overall, the records from the specialized mobility evaluation do not support the medical necessity of a power mobility device such as a power wheelchair for accomplishing basic mobility-related activities of daily living.  This patient would benefit from increased upper body physical activity and exercise.  Manual wheelchair use has been shown to provide significant health benefits over power wheelchair use for persons with mobility impairments due to conditions such as spinal cord injury.  There are no documented impairments that would limit or restrict regular manual wheelchair use in a household setting.  All told, the requested power wheelchair is not medically necessary for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

Physician 1: The patient is a 61-year-old female who has a history of post-traumatic herniated lumbar discs at L3-4 with lumbar radiculopathy. She has under gone provocative L3-4 discogram and microdecompressive lumbar discectomy at L3-4 in November 2004. In addition, the records indicate the patient also has deep vein thrombosis (DVT) and was taking Coumadin therapy at the time of the procedure. Since the patient has a history of clotting complications, the patient states it was best for her to undergo the least invasive procedure possible. She is requesting reimbursement for the procedure at issue. Percutaneous laser discectomy (PLD) is an investigational and experimental procedure without established clinical efficacy. Despite anecdotal evidence and reported successes, validation of its clinical benefit remains elusive. Furthermore, there were other proven treatment modalities available to this patient at the time she underwent surgery. Therefore, I have determined that the procedure at issue was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld.Physician 2: This 61-year-old woman has degenerative disc disease. She underwent laser disc surgery in November 2004. She is requesting reimbursement for the procedure. The Health Plan has denied this request indicating the procedure at issue is considered experimental.There is no data to support laser discectomy over standard open surgery. The standard procedure could have easily been performed in this case (even with her blood clot history). There is no medical justification for performing the laser procedure in this case.Therefore, I have determined that the procedure at issue was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld.Physician 3: The patient is a 61-year-old female with disc degeneration and herniation at L3-4 who underwent provocative lumbar discography and subsequent laser disc decompression surgery at L3-4 in November 2004. The issue in this case is whether the procedure at issue was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. I recommend the denial be upheld. Laser disc decompression/microdiscectomy via laser thermodiscoplasty has not been proven to likely be more beneficial than standard microdiscectomy and/or interbody fusion. Therefore, I have determined that the procedure at issue was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

The mother of a 16-year-old female enrollee has requested rhinoplasty for the treatment of the enrolle's nasal condition. Findings:  The physician reviewer found that the photographs submitted reveal a minimal bony dorsal hump and no collapse of the nasal tip. The bony dorsal hump did not constitute an abnormal structure, and its correction would not offer more than minimal improvement in appearance. The photographs do not support obstruction of nasal vestibules or otherwise document nasal malfunction. Thus, rhinoplasty would not improve nasal function.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for custom fit orthotics/shoe inserts.Custom functional orthotics have been standard of care for the treatment of plantar fasciitis for many years. Custom orthotics are fabricated to be firmer and more functional with respect to controlling the patients foot and allowing relief of stress and strain to the plantar fascia. Functional orthotics are made from a casting of the patients foot, allowing for a better and more precise fit. In this case, the progress notes document painful left plantar fasciitis. X-rays reveal no stress fracture. Records show that this patient has failed conservative treatments, including home stretching, local corticosteroid injection to left heel, physical therapy, and diclofenac. Therefore, the requested custom fit orthotics/shoe inserts are medically necessary to treat 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested digital breast tomosynthesis for evaluation of the enrollees risk for breast cancer. Findings: Two reviewers found that tomosynthesis was approved by the U.S. Food and Drug Administration (FDA) for clinical use. Despite the lack of long-term studies proving an increased survival rate when tomosynthesis has been used as part of screening mammography, the American College of Radiology (ACR) urged the technique be removed from the investigational due to the advantages this new tomographic technique brings to radiologists interpreting mammograms. This technique often allows radiologists to separate dense glandular elements from underlying masses and architectural distortion resulting in a decrease in callbacks and increased detection of small cancers. Thus, the addition of tomosynthesis to the usual two-dimensional protocol is likely of greater benefit to this patient than two-dimensional imaging alone. Accordingly, the breast tomosynthesis is likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: Two reviewers determined that the diagnostic procedure at issue is likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: All three physician reviewers are board certified in 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

A 46-year-old female enrollee requested authorization and coverage of intravenous antibiotic therapy. The Health Plan  denied this request indicating that the requested therapy is not medically necessary for treatment of the enrollees Lyme disease.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested therapy is not medically necessary.