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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for bariatric surgery evaluation and follow-up for treatment of the enrollees obesity.  Findings:  The physician reviewer found that The submitted documentation supports the medical necessity of the requested services. There is no published or scientifically supported standard to deny bariatric evaluation based on failure to complete a specified number of physician supervised weight loss months. The records document a body mass index of 45.10 kg/m2, and this patients comorbidities include hypertension and type 2 diabetes. The medical evidence supports the requested services in this clinical setting. Therefore, the requested bariatric surgery evaluation and follow-up 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 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 parent of an enrollee has requested reimbursement for the mental health residential treatment center (RTC) services provided.Findings:  The physician reviewer found that the records provided for review document that by  the date of dispute, the patient had excellent insight. The providers indicated that the patient had no suicidal or homicidal ideation or evidence of psychosis and no significant symptoms of eating disorders or of problems sleeping. She was noted to have met all treatment goals and no longer required 24-hour supervision and monitoring. Given the patients presentation on the date of dispute, she was a candidate for treatment at a less restrictive level of care. Thus, the mental health RTC services provided  were not supported as medically necessary for treatment of this patients behavioral health issues.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 with sub-specialty certification in child and adolescent 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for percutaneous tibial nerve stimulation. The Health Plan has denied this request indicating that the requested services are considered investigational for treatment of the enrollees medical condition.Findings:  There is support in the medical literature for the requested services in this clinical setting.  Percutaneous tibial nerve stimulation is considered to be an appropriate salvage therapy for this patient.  This patient underwent urethral sling surgery which subsequently failed. The patient underwent removal of the urethral sling followed by urethrolysis procedure. Currently she is on medication with good improvement. The record notes that she has tried behavioral therapy, dietary changes, physical therapy, and multiple pharmacotherapy. At this time, the patient has failed multimodal primary and secondary treatments for her condition. The studies support the use of percutaneous tibial nerve stimulation to be an appropriate salvage therapy. Therefore, based on the documentation provided as well as the medical literature, percutaneous tibial nerve stimulation is likely to be more beneficial than the standard treatment options available for treatment of this patients medical condition.Final Result: Two of the three reviewers determined 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:  All three reviewers are board certified in urology 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: Upheld

A 56-year-old male enrollee has requested Amitiza for the treatment of his irritable bowel syndrome. Findings:  The physician reviewer found that the FDA approval of Amitiza clearly states that the drug is not approved for use in men due to a lack of clinical evidence supporting its safety and efficacy in the male patient population. Published clinical studies on Amitiza included only a small number of men and were primarily focused on its effects in women. Although the submitted records state that the patient failed treatment with Miralax, continued constipation would actually constitute failure while his resultant diarrhea essentially amounted to an over-response. There is no mention of the patient titrating the dose of Miralax down to improve his constipation symptoms without causing diarrhea.
Appeal type: Medical Necessity
Decision: Upheld

The patient has requested authorization and coverage for Lenvima 24 mg daily dose pack, 90 each per 30 days. This patient presents with stage IV metastatic recurrent vulvar cancer. She has been treated with chemotherapy regimens. The patients provider recommended treatment with Lenvima based on molecular profiling results. However, Lenvima is not U.S. Food and Drug Administration (FDA) approved for the treatment of vulvar cancer. Moreover, there is a paucity of peer-reviewed medical literature demonstrating improved patient health outcomes, or major drug compendia supporting an indication for Lenvima in this clinical setting. Researchers reported findings that Lenvima has antitumor activity consistently across diverse unresectable hepatocellular carcinoma models. Overall, the medical literature includes case reports on Lenvima, but there is a lack of larger trials establishing the safety and efficacy of Lenvima in patients with vulvar cancer. Given these findings, the requested Lenvima 24 mg daily dose pack, 90 each per 30 days is not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested medication 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 internal medicine with subspecialty certifications in medical oncology and hematology 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 38-year-old female enrollee requested authorization and coverage of further infertility services.  The health plan denied the enrollees request indicating that further infertility services are not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer overturned the health plans denial on the basis that the requested services are medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

The parent of an eleven-month-old female enrollee has requested for measles, mumps, and rubella (MMR) vaccines to be given separately, rather than in the combined version for treatment of the enrollee. Findings:  The physician reviewer found that there are no evidence-based, peer-reviewed studies to support a link between the MMR vaccine and autism. Furthermore, there is no published scientific evidence showing that there is any benefit to separating MMR vaccine into three individual shots.
Appeal type: Medical Necessity
Decision: Upheld

A 59-year-old male enrollee requested Orthovisc injections for medical treatment of his osteoarthritis.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  This patient has had multiple injections and with each injection and each exposure to the antigen, there is an increased risk of allergic response.  There is also a risk of iatrogenic infection being introduced into the joint during the process of injection.  Rutjes and colleagues performed a meta-analysis of the efficacy of viscosupplementation.  The authors concluded that viscosupplementation is associated with a clinically irrelevant benefit and an increased risk of serious adverse effects.  All told, the requested Orthovisc injections are not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for repair of nasal vestibular stenosis, with the approved septoplasty or submucous resection, with or without cartilage scoring, contouring or replacement with graft, and/or bilateral submucous resection of inferior turbinate, partial or complete. Based on available clinical documentation, the requested nasal vestibular stenosis repair, septoplasty, and turbinate reduction is medically necessary to adequately treat this patients intranasal valve stenosis turbinate hypertrophy. In the peer-reviewed medical literature, van Egmond and colleagues published a randomized controlled trial comparing surgery to non-surgical modalities for the treatment of patients with nasal obstruction with a deviated nasal septum. The authors concluded that septoplasty was more effective than non-surgical management in improving objective and subjective measures at 24-month follow-up. Additionally, the American Academy of Otolaryngology-Head and Neck Surgery (AAOHNS) clinical practice guidelines states that septorhinoplasty can improve the nasal airway in well selected patients, as in this patients clinical setting (Ishii, et al.). Given this support, the requested repair of nasal vestibular stenosis, with the approved septoplasty or submucous resection, with or without cartilage scoring, contouring or replacement with graft, and bilateral submucous resection of inferior turbinate, partial or complete are medically necessary for 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 otolaryngology 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:  A 56-year-old female enrollee has requested reimbursement for advanced lipoprotein testing (CPT code 83695) that was provided for treatment of hypercholesterolemia. Findings:  The physician reviewer found that there are some researchers advocating the use of the advanced lipoprotein analysis, the American College of Cardiology (ACC) guidelines do not support the use of advanced lipid testing. Rather, these guidelines recommend the use of standard risk factors and standard lipid profile testing to make decisions about lipid management. The guidelines have moved away from specific target values and emphasize the use of the pooled risk score analysis for decisions regarding statin therapy. Medical evidence does not support the superior efficacy of the services at issue. The patient has severe hyperlipidemia, but no other clinical risk factors for cardiovascular disease. She was referred for advanced lipoprotein testing to further stratify her cardiovascular disease risk and plans for possible therapy. In this clinical instance, her elevated low-density lipoprotein (LDL) level was an indication to start lipid-lowering therapy. Therefore, advanced lipoprotein testing provided was not likely to have been superior over other methods of evaluating this patient. Final Result: All three reviewers have determined that the advanced lipoprotein testing provided was not likely to have been more effective than other methods of evaluating this patient. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications:  All three reviewers are board certified in internal medicine with sub-specialty certification in cardiovascular disease, and 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: The patient has requested authorization and coverage for Monovisc (hyaluronic acid) injection in each knee. Per the 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 is trying other conservative treatments, with the alternative being a total knee arthroplasty at a relatively young age. Given the patients limited options and based on the current medical literature, the requested services are medically indicated. Therefore, Monovisc (hyaluronic acid) injection in each knee is 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: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Supartz injections in both knees. Findings:  The physician reviewer found that he 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 a history of osteoarthritis in both knees and of relief using viscosupplementation three years prior. She has tried and failed other conservative treatments, including oral and topical non-steroidal anti-inflammatory drugs, cortisone injections, physical therapy, and a home exercise program, with the alternative being bilateral total knee arthroplasties. Given the patients limited options and based on the current medical literature, the requested services are medically indicated. Therefore, Supartz injections in both knees are medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested service is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in 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 29-year-old male enrollee requested magnetic resonance imaging (MRI) for medical evaluation of his right posterior knee and calf pain.  Findings:  The physician reviewer found that the patient presents with point tenderness of the right proximal calf consistent with gastrocnemius strain or tear. No profound weakness is described. MRI has been requested to differentiate between tear and strain. The literature demonstrates that surgical treatment of gastrocnemius rupture is rare and conservative management is considered the standard of care. Ultrasound has been described as being useful in the differentiation between tear and strain and is a good first-line exam. Since the treatment is almost always conservative, the requested MRI is not medically necessary since the treatment will likely be conservative even if a tear is found.
Appeal type: Medical Necessity
Decision: Overturned

A 19-year-old female enrollee has requested physical therapy services for the treatment of her proximal femoral focal deficiency. Findings:  The physician reviewer found that the physical therapy progress notes demonstrates steady improvement in range of motion in left knee, and hip, and continued difficulty with increased weight bearing due to limited bone growth. Left knee flexion was reported to be 130 degrees, and extension -20 degrees. The patients pain decreased to 2-6/10, knee flexion was increased to 128 degrees, knee extension was 16 degrees active and 10 degrees passive, hip flexion increased to within normal limits, hip extension increased to 10 degrees and strength in the knee muscles increased to 4/5. The patient was ambulating 2 minutes without crutches at 50% weight bearing, but still not at her prior level of functioning. She received continued physical therapy with exercises, and manual treatment. The patient continued to show progress in all areas especially with range of motion and strength in the left knee/hip/ankle. Gait remained an issue due to continued bone regeneration, but the patient was able to improve in other areas with continued therapy.
Appeal type: Experimental/Investigational
Decision: Upheld

A 41-year-old female enrollee has requested for artificial disc replacement L4-L5 for treatment of her condition.   Findings:  Two physician reviewers found that artificial disc replacement is also not indicated in light of shortened pedicles, hypertrophy of flavum and significant disc bulge. Decompression, decompression and discectomy and/or fusion are alternatives that are likely to be more efficacious for this patient.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a two-year-old male enrollee has requested speech therapy for treatment of the enrollees cerebral palsy.  Findings:  The physician reviewer found that review of the record indicates the patient is significantly developmentally delayed.  However, he has made definite progress and has shown significant improvement in ambulation, communication (pointing) and self-help skills (feeds with a spoon). He has been diagnosed with cerebral palsy, a disorder of brain development.  As he has shown improvement while receiving physical and occupational therapy, it is highly probable that the patients expressive and receptive language delays will improve with individual speech therapy.    The scientific literature demonstrates that speech therapy can be extremely effective for a speech delay in this patients age group. The effectiveness of speech therapy in a young child is emphasized in several of the references cited above. A paper by Law et al., reports that children with speech delay can be readily treated, as confirmed in a review of multiple medical journal articles. Goorhus-Brower, et al. specifically examines children with speech delay, including both cognitively normal as well as developmentally delayed children, and points out that both groups are candidates for successful speech therapy. All told, the benefit of speech therapy for young children with speech delay is well documented. The submitted medical records demonstrate the patient is an appropriate candidate for speech therapy, and therefore, the requested services should be authorized.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 60-year-old female with a maternal grandmother with colon cancer and a father with colon cancer. She is otherwise asymptomatic. The patient has requested authorization and coverage for a colonoscopy. The Health Plan has denied the request on the basis that the requested colonoscopy is not medically necessary for evaluation of the patients medical condition. Based upon the information provided, it appears the patient has never undergone endoscopic evaluation. She has a first-degree and a second-degree relative with colon cancer. For persons with a single first-degree relative diagnosed with colorectal cancer at age 50 or older, there is approximately a two times greater risk of colon cancer than that observed in the general population. Furthermore, the risk for colon cancer at age 40 for such persons is the same as the risk in the general population at age 50. Thus, in this risk group screening should begin at age 40 rather than age 50. The patient meets medical necessity criteria for a colonoscopy. Therefore, I have determined that the requested colonoscopy is medically necessary for evaluation of the patients medical condition. The Health Plans denial should be overturned.