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

A 38-year-old male enrollee has requested sinus surgery, nasal endoscopy with sinus ostia dilation using a balloon device (CPT codes 31296 and 31295)for treatment of his chronic sinusitis. Findings:  Three physician reviewers found that the requested services are not likely to be more efficacious than other available treatment options in this patients case.  Per the medical records, this patients symptoms do not suggest the need for sinus surgery.  As noted in the submitted documentation, the patient had nasal congestion and allergic rhinitis.  The current medical evidence does not support sinus surgery in this clinical setting.  In this case, the requested sinus surgery, nasal endoscopy with sinus ostia dilation using a balloon device (CPT codes 31296 and 31295) is not likely to be effective.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for percutaneous tibial nerve stimulation (PTNS) for treatment of the enrollee who has a history of overactive bladder. Findings:  Two physician reviewers found that this patient is symptomatic with overactive bladder symptoms including urgency incontinence. There is evidence of the effectiveness of short term PTNS in treatment of OAB. According to the American Urological Association (AUA) incontinence guidelines, percutaneous tibial nerve stimulation is considered an appropriate salvage therapy for patients with intractable irritative lower urinary tract symptoms including urgency incontinence.  This patient has failed multimodal therapy. Furthermore, she has urinary retention most likely related to diabetes mellitus. The records note that she has exhausted most of her treatment options for her condition. The patient is not a candidate for Botox injections secondary to urinary retention. Final Result: The reviewers determined that the requested services are 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: Reviewers 1, 2 and 3 are board certified in urology 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential treatment center services provided for treatment of the enrollees behavioral health condition.Findings: The physician reviewer found that based on the Level of Care Utilization System for Psychiatric and Addiction Services (LOCUS) criteria to determine the appropriate levels of care the patient scored 15 meeting criteria for outpatient treatment. The patients risk of harm score is two (2), low risk of harm. The documentation did not show a history of any suicide attempts or suicidal ideation. The patient did have a DUI in which she was under court mandate for treatment. The patients functional status score is two (2), mild impairment. The records showed that the patient had minimal prior treatment. She participated in Alcoholics Anonymous (AA) for seven months. She had some interpersonal problems with her family but was functioning in her self-care and usual activities. Her medical and psychiatric co-morbidity score is two (2), minor co-morbidity. The patient has a co-morbidity of major depressive disorder which was well controlled on Lexapro. She did not have any major medical problems. Her recovery environment score is two (2), mildly stressful environment. The patient has some interpersonal problems with her parents. Her level of support score is two (2), supportive environment. The patients parents are willing to participate in treatment if requested to do so. Her recovery history score is three (3), moderate response to treatment. The patient had limited prior treatment for her alcohol use disorder. She participated in AA for seven months, but this did not lead to complete remission of her alcohol use. Her engagement status score is two (2), positive engagement and recovery. The patient has a positive attitude toward recovery and treatment and is cooperative with staff and treatment recommendations. Based on these criteria, the patient met criteria for outpatient treatment. Therefore, the patient could have been treated in a less restrictive environment during the dates in dispute.Final Result: The reviewer determined that the services at issue were not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified 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: Overturned

The patient is a five-year-old female with a history significant for cleft palate and chromosomal abnormalities complicated by recurrent otitis media requiring bilateral myringotomies x 3. The patient has been receiving speech therapy for expressive and receptive language delays, oral motor production disorders, and verbal apraxia. There is also mention of an auditory processing disorder, but no discussion of symptoms associated with this disorder. A request has been made for coverage of speech therapy twice a week. The Health Plan has denied this request. Although further standardized testing would be helpful for this patient, the goals outlined are functional in nature. In addition, records demonstrate the patient has made significant gains towards her goals. For example, her expressive language has increased to 100 words and there has been a marked increase in her phonic inventory. Because the patient is making objective significant gains, further therapy is medically indicated. The patient should continue to receive speech therapy for another six months, at which time she should be re-evaluated to determine whether she is meeting objective, functional goals.Based upon the information set forth above, I have determined the therapy at issue is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested shoe inserts for treatment of her severe osteoarthritis and plantar fasciitis in both feet. Findings: The physician reviewer found that after review of the submitted clinical documentation, the requested orthotics are medically necessary to treat this patient's plantar fasciitis and midtarsal joint osteoarthritis. It is established in the progress notes that this patient is experiencing painful plantar fasciitis. Per the submitted documentation, custom functional orthotics have been used for many years to inhibit over pronation of both the subtalar joint and midtarsal joint, in treatment of plantar fasciitis and midtarsal joint osteoarthritis. These devices biomechanically support the foot and offload the painful area. Orthotic devices are considered standard of care for the treatment of plantar fasciitis and midtarsal joint osteoarthritis. For these reasons, the requested shoe inserts are medically necessary for treatment of the patients severe osteoarthritis and plantar fasciitis in both feet.  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 an Afirma gene expression classifier for evaluation of the enrollees thyroid nodule.  Findings: All three physician reviewers found that the patient was diagnosed with a thyroid nodule found to be indeterminate atypia of indeterminate significance. Per the provider, the genetic testing was to ascertain if the nodule was benign or malignant. The patient is requesting reimbursement for the provided Afirma gene expression classifier. The Health Plan denied reimbursement. Per the Health Plan, the services at issue were investigational for evaluation of the patients medical condition. All three reviewers determined there is sufficient support for the services at issue in this clinical setting. The patients initial biopsy report came back as indeterminate atypia of undetermined significance, but the genetic testing showed that it was a suspicious lesion. This was a major determining factor in delineating further course of action and to see if a possible surgical procedure was warranted. Afirma testing is generally considered standard protocol on all fine needle aspirations performed on thyroid nodules in order to avoid needless surgeries. In this patients case, Afirma test results influenced the course of action for treatment of her thyroid nodule. Therefore, the Afirma gene expression classifier was likely to be more efficacious than other methods of evaluating of this patient.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 internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism and is actively practicing. The reviewers are 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 female enrollee has requested for laparoscopic duodenal switch procedure for treatment of her morbid obesity.    Findings:  The physician reviewer found that there is also a large body of scientific data that discusses the different types of surgical weight loss procedures. Buchwald and colleagues summarized the outcomes of different types of surgical weight loss procedures based on excess weight loss and resolutions of co-morbid conditions. The duodenal switch procedure was determined to show the most improvements among bariatric procedure alternatives (including Roux-en-Y gastric bypass, gastroplasty and gastric banding). There was significant hyperlipidemia improvement, diabetes resolution and excess weight loss reported with the duodenal
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for autologous chondrocyte transplant and right tibial osteotomy.Findings:  Two of the three physician reviewers found this patient presented with a history of chronic persistent right knee pain with associated swelling, popping, clicking, and locking. Clinical examination findings were reported by the treating provider to be consistent with chondromalacia patella and maltracking of the patella. However, documented clinical findings did not evidence patellar malalignment or maltracking. The medical literature supports autologous chondrocyte implantation for large chondral lesions in patients who failed operative and nonoperative treatment. A tibial tubercle osteotomy is recommended at the time of autologous chondrocyte implantation to achieve realignment. However, in this case, the patient does not have a large chondral lesion or significant evidence of malalignment consistent with evidence-based medical literature criteria. Therefore, the requested autologous chondrocyte and right tibial osteotomy is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested services are 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 orthopedic surgery 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 55-year-old female enrollee has requested for outpatient therapy for treatment of her depression. Findings:  The physician reviewer found that effective psychotherapy is a trusted intervention in the treatment armamentarium for those diagnosed with affective disorders, such as major depressive disorder and it is also a first-line treatment for those assessed with generalized anxiety disorder. Current practice is focused on aggressive treatment, particularly in the acute phase of the illness, followed by less frequent services in the maintenance phase to foster patient autonomy and recovery. This concept is effectively captured in the following excerpts from the American Psychiatric Association Clinical Practice Guideline: The optimal frequency of psychotherapy has not been rigorously studied in controlled trials. The psychiatrist should consider multiple factors when determining the frequency for individual patients, including the specific type and goals of the psychotherapy, the frequency necessary to create and maintain a therapeutic relationship, the frequency of visits required to ensure treatment adherence, and the frequency necessary to monitor and address suicide risk and other safety concerns. Time-limited brief psychotherapies may mobilize many depressed patients to more rapid improvement. Regardless of the type of depression-focused psychotherapy that is selected, the clinician should carefully and systematically monitor the patients response to treatment, which can be facilitated by the use of clinician and patient rated scales at regular intervals. If four to eight weeks of treatment do not yield at least moderate improvement, of a 20% diminution in symptoms, the clinician should thoroughly review and reappraise the treatment plan. Generalities notwithstanding, it is not uncommon for weekly psychotherapy sessions in times of crisis or excessive symptom burden to be medically necessary and consistent with good medical practice in the psychiatric community.  However, the records provided do not support the current need for such a frequency of treatment. Based on the documentation, weekly psychotherapy sessions are not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 34-year-old female enrollee has requested for partial hospital mental health therapy for treatment of her anorexia nervosa. Findings:  The physician reviewer found that the patient continued to have anxiety and some depression and there was some ambivalence regarding taking prescribed medications. However, these concerns could have been appropriately addressed at a less intensive level of care. Based upon the American Psychiatric Association guidelines, the patient was a candidate for a range of outpatient services.
Appeal type: Experimental/Investigational
Decision: Overturned

A 62-year-old male enrollee has requested for canaloplasty for treatment of her glaucoma. Findings:  Two physician reviewers found that clinical evidence reveals that in this circumstance, further intervention is needed to preserve the patients vision. Canaloplasty is a relatively new procedure that has been shown to result in good outcomes when performed by experienced surgeons. The medical literature supports the efficacy of this procedure.  For example, a study by Lewis and colleagues was performed to evaluate the safety and efficacy of circumferential viscodilation and tensioning of the inner wall of Schlemm's canal (also known as canaloplasty), a new surgical procedure for the treatment of open-angle glaucoma (OAG). Evaluation was performed at baseline and 1 day, 1 week, and 1, 3, 6, and 12 months. The authors concluded that canaloplasty was a safe and effective surgical procedure to reduce IOP in adult patients with OAG.
Appeal type: Medical Necessity
Decision: Overturned

A 58-year-old female enrollee has requested additional physical therapy for treatment of her status post shoulder surgery. Findings:  The physician reviewer found that this patient is status post left shoulder hemiarthroplasty with a complicated postoperative course.  She has been responding to the prescribed physical therapy program.  She continues to require the skills of a licensed physical therapist in order to continue to progress and recover shoulder function.  Similar recovery cannot be achieved through an unsupervised exercise program.  In this setting of severely restricted range of motion of the shoulder following shoulder hemiarthroplasty, a prolonged course of physical therapy is indicated.  In this patients case, additional physical therapy is medically indicated.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a three-dimensional (3D) mammogram for evaluation of her breast cancer.  Findings:  The physician reviewer found that although tomosynthesis is not routinely used as a part of screening mammography, this patient has unique circumstances. First, the patients breast tissue has been described as heterogeneously dense which limits the utility of standard mammography. Second, the patient has known Lobular Carcinoma In Situ in the remaining left breast as well as a family history of breast cancer. Since Lobular Carcinoma In Situ is more difficult to visualize on mammography, and in light of the patients circumstances, the addition of tomosynthesis is appropriate in this case. All told, the requested 3D mammogram is supported as medically necessary for evaluation of this patients medical condition. Final Result: The reviewer determined that the requested service 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 diagnostic radiology 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 authorization and coverage for  LINX procedure. Findings:  The physician reviewer found that The U.S. Food and Drug Administration (FDA) approved the LINX procedure for lower esophageal sphincter augmentation. Eligible patients for the procedure include those with inadequate symptom control with acid suppression therapy, including those patients with mild to moderate gastroesophageal reflux disease (GERD) and a hiatal hernia less than 3 cm. A recent retrospective  study comparing the LINX procedure with laparoscopic fundoplication concluded that GERD patients had similar control of reflux symptoms after both LINX and fundoplication. The authors noted that the inabilities to belch and vomit were significantly fewer with LINX, along with a significantly lower incidence of severe gas-bloat symptoms. A five-year cohort data was recently published establishing the durability of the LINX procedure. In a group of 85 patients augmentation of the lower esophageal sphincter with a magnetic device provided significant and sustained control of reflux, with minimal side effects or complications. Based on this patients history and current symptoms, her provider recommended treatment with the LINX procedure. However, this patient is not ideal for the LINX device given the presence of a hiatal hernia measured at 5 cm and cyclic vomiting syndrome. Recurrent episodes of forceful vomiting will result in tremendous stress at the gastroesophageal junction. All told, the requested LINX procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Findings: Three of the three physician reviewers found the requested LINX procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: The reviewers determined that the requested services are 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 reviewer 1 is board certified in internal medicine with subspecialty certification in gastroenterology and is actively practicing. Physician reviewer 2 is board certified in internal medicine with subspecialty certification in gastroenterology and is actively practicing. Physician reviewer 3 is board certified in internal medicine with subspecialty certification in gastroenterology 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 41-year-old male enrollee has requested Levitra or Viagra for treatment of his erectile dysfunction.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medications.  The evaluation of a patient with new onset of erectile dysfunction should include a general medical examination and testing of testosterone level to evaluate for underlying causes.  Any underlying causes should be evaluated and addressed prior to initiating treatment for erectile dysfunction.  In this patients case, the clinical notes do not indicate that underlying causes of erectile dysfunction have been fully evaluated or addressed.  The current medical evidence does not support the requested medications in this setting.  All told, neither Levitra nor Viagra are medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 9-year-old male enrollee requested 32 hours per week of one-on-one applied behavioral analysis (ABA) therapy; 2 hours per month of parent training and 8 hours per month of ABA supervision for medical treatment of the enrollees autism spectrum disorder (ASD).  Findings:  The physician reviewer found that the medical literature supports ABA services in this clinical setting. One-on-one therapy at a frequency of 24 hours per week is medically appropriate and necessary to reinforce acquired skills and allow for ongoing trials with other skills. The alternative service of 15 hours per week of ABA therapy is a significant reduction from the 32 hours of weekly therapy the patient had been receiving and would likely lead to regression in skills already acquired and slowing of progress. As such, ABA services at the frequency of 24 hours per week of one-on-one ABA therapy; 2 hours per month of parent training and 8 hours per month of ABA supervision are medically necessary for treatment of the patients medical condition.