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 Lap Sleeve Gastrectomy (CPT 43775).The submitted documentation supports that the requested services are medically necessary. By standard, a patients original weight at the time of their initial presentation is the weight that is recorded and utilized for weight loss surgery evaluation. Standard published guidelines support the use of a patient's initial weight in the bariatric program when determining eligibility. It is understood that a patient with a BMI of 35 kg/m2 who is forced to proceed with insurance mandated weight loss may then lose weight. This is in preparation for bariatric surgery, however, and it is understood that without a definitive tool, the patient would likely regain all of their weight and more. In this case, the patient has no evidence of barriers to surgery, and it is her original weight and BMI, together with her completed dietary and behavioral evaluations, that establish that she meets guidelines for treatment of morbid obesity. Accordingly, the requested Lap Sleeve Gastrectomy (CPT 43775) is medically necessary for the patients medical condition.Final Result: The reviewer determined that the requested services are medically necessary for the patient's 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: Experimental/Investigational
Decision: Upheld

A 39-year-old female enrollee has requested ultrasound-guided sclerotherapy for the treatment of her varicose veins. Findings:  Three physician reviewers found that generally sclerotherapy is not used as primary treatment for greater saphenous reflux. In the case of this patient, sclerotherapy was used as sole therapy for treatment of the saphenous vein reflux. There is a lack of medical literature supporting the efficacy of sclerotherapy in this setting. There are other minimally-invasive options such as endovenous laser therapy and radiofrequency ablation, which have a lower rate of recurrence as compared to sclerotherapy.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 34-year-old female with a very long-standing history of anorexia, beginning at age 14-15 years of age.  There are recurrent episodes of severe caloric restriction along the way. Her eating patterns hampered her completion of medical school and ultimately led to inpatient treatment in 1998.  After withdrawal from medical school the patient later attempted business school but, in spite of continued outpatient treatment, she suffered another relapse.  When admitted to residential treatment in January 2005, the patient only weighed 91.5 pounds (65% of her ideal body weight) and was diagnosed with generalized anxiety disorder (GAD), anorexia nervosa, mood disorder, and avoidant personality disorder. She reported restricting her daily calories to anywhere from 800 to 1,000 calories or simply having stopped eating while in MBA school. She also noted taking long walks for about an hour each day and suffering disrupted sleep. The admission physical exam revealed her to be frankly cachectic and bradycardic, and she had dystrophic nails, orthostatic hypotension and a sacral pressure ulcer. Her blood work revealed anemia (hemoglobin and hematocrit of 10.7 and 30.1 respectively), hyponatremic (sodium 129), and with elevated liver function tests. She was amenorrheic with her last period occurring two years prior. By February 2005, two months into treatment, her H/H had improved to 11.4/43.3 and sodium to 131. She was treated with a combination of psychotherapies, Risperdal, and Celexa, and felt to have gained sufficient weight by March 2005 to allow for discharge.The Health Plan has denied authorization for residential psychiatric treatment services provided from January 2005 through March 2005 based upon their determination that the services were not medically necessary.Based on the submitted documentation including the notes cited above, it is apparent that the patients illness was severe and did warrant residential treatment. For example, her admission physical exam reflected signs of frank starvation. Various psychiatric notes reflect the patients dysphoria and anxiety over properly gaining weight, and this appears quite consistent throughout all of the notes. Although the patient did eventually gain enough weight to allow for discharge, going from an admission weight of 91.5 pounds to a discharge weight of 104.2 pounds, she only achieved 78% of her ideal body weight. She was noted to express urges to restrict her calories and a continuing reluctance to gain more weight. That the patient did not gain an enormous amount of weight does not mean that the treatment afforded was not medically indicated; rather, it speaks to the severity of her illness. All told, I find that continued residential treatment from January 2005 through March 2005 was medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a three-year-old male enrollee has requested one-on-one speech therapy and apraxia testing for the treatment of the enrollees apraxia. Findings:  Three physician reviewers found that the submitted evidence demonstrates that the patient has significant speech delay and demonstrates autistic characteristics. The American Speech-Language Clinical Hearing Association indicates that children in this setting benefit from assessment and intervention services provided by speech-language therapists. Greatest efficacy results from early intervention, intensive instruction and individualized objectives. Given that this patient is at least two standard deviations behind in speech, one-on-one speech therapy and apraxia testing are medically appropriate and indicated.
Appeal type: Medical Necessity
Decision: Overturned

A 19-year-old male has requested coverage for seven days of residential treatment center services for treatment of his behavioral health issues.  Findings:  The physician reviewer found that based on review of the available records, the patient had a complicated history prior to admission, and presented a clear and consistent danger to himself from frequent suicidal thoughts. The records indicate that in addition to suicidal ideation, the patient had acted upon these thoughts twice prior to admission. His clinical course prior to admission was diagnostically confusing, as he presented with clear manic features as well as depressive features but failed to respond to the anti-manic medications Abilify and Depakote. For these reasons, upon admission, the psychiatrist appropriately chose to discontinue all previous medications and re-evaluate the patient. The provider then treated the patient primarily for depression with Prozac. When the provider documented that the patient was showing more signs of anxiety and depression, this indicated a risk factor that necessitated further evaluation and monitoring. Thus, it was appropriate and medically necessary for the patient to remain in the hospital for close observation during the first six days of his stay. However, by the seventh day, the neuropsychological evaluation was completed, and did not show any additional problems, the patient had responded to treatment, and could at that time have been safely transitioned to a lower level of care.
Appeal type: Medical Necessity
Decision: Upheld

A 35-year-old female enrollee has requested laparoscopic gastric banding (Lap-Band) for treatment of her obesity.  Findings:  The physician reviewer found that this patient does not meet standard criteria for bariatric surgery at this time. Specifically, the patients records do not document clinically severe obesity with a BMI of 40, or morbid obesity with a BMI of 35 and serious co-morbid medical conditions. In addition, there is no documentation that the patient previously met the criteria including completion of dietary and behavioral evaluations for initial placement of the Lap-Band in March 2012. Overall, bariatric surgery is not medically necessary for this patient based on the lack of documentation of clinically severe or morbid obesity.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for skilled nursing facility admission including physical therapy and occupational therapy for treatment of the enrollee, who sustained a hip injury after falling. Findings:  The physician reviewer found that the skilled nursing facility level care was not medically necessary. The patient had a unilateral lower extremity impairment. She was weight bearing as tolerated and had a slightly limited prior level of function requiring a cane. The patient had purchased a walker.  The documentation did not indicate complex wound care needs. Her medical condition was stable and her pain was being managed with oral medications. She was able to ambulate greater than household distances and perform essential activities of daily living without hands-on assistance. The patient did not require physician oversight of her condition on an inpatient basis. The patients care needs could have been met at an alternative level of care such as home based or outpatient level of care. Therefore, based on the reasons stated above, the three additional days including physical therapy and occupational therapy at a skilled nursing facility were not medically necessary for the treatment of this patient. 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 physical medicine and rehabilitation with sub-specialty certification in pain management 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

A male enrollee requested single photon emission computed tomography (SPECT) scans for medical evaluation of his attention deficit/hyperactivity disorder.  Findings:  Three physician reviewers found that the submitted documentation fails to demonstrate the superior efficacy of the services at issue.  The patient had already been diagnosed with attention deficit/hyperactivity disorder, hypothyroidism and depression.  The treatment recommendations in the record include having the patient refrain from smoking marijuana and excess alcohol, and to engage in a healthy diet and exercise plan as well as psychotherapy utilizing cognitive behavioral therapy.  These general recommendations for treatment are fairly standard and do not require a SPECT scan for support.  There is no evidence that this patient meets these criteria.  In sum, SPECT scans were not likely to have been superior over other methods of evaluation.
Appeal type: Medical Necessity
Decision: Upheld

A 51-year-old female enrollee has requested a PET scan for evaluation of her thymoma. Findings:  The physician reviewer found that there are only several small studies and case reports examining the role of PET scans in thymic tumors. A study of 25 patients with thymic pathology concluded that PET is useful in patients who have undergone thymoma excision when there is suspicion of recurrence or metastasis (El-Bawab, et. al.). In another study involving 33 patients it was felt that PET scan was useful for differentiating subgroups of thymic epithelial tumors and for staging the extent of the disease (Sung, et. al.). However, at the end of the discussion the authors acknowledged that the study was small and that further studies were needed such as direct comparison between PET and the relationship between SUV values and patient outcomes. Finally, a study of 31 patients, which included 9 thymic carcinomas, showed a SUV of 5 achieved a sensitivity of 84.6% in differentiating thymic cancer from thymoma (Sasaki, et. al.).Because only small studies have been performed, the role of PET in thymic tumors is still unproven. Considering that the density in the patients anterior mediastinum had been stable since July 2004, and there was no evidence given for suspicion of recurrence, a follow-up diagnostic CT would have been the examination of choice in this case.
Appeal type: Medical Necessity
Decision: Upheld

A 53-year-old male enrollee has requested a magnetic resonance imaging (MRI) for evaluation of his low back pain.   Findings:  The physician reviewer found that this patients records do not demonstrate any history of trauma. Further, on physical evaluation, the provider found no radiculopathy or neurological deficit. With regard to the clinical utility of MRI in evaluating patients with LBP, Modic and colleagues concluded that, MR imaging does not appear to have measurable value in terms of planning conservative care. As reported by the American College of Radiology (ACR), Acute low back pain with or without radiculopathy is one of the most common health problems in the United States. Thus, due to this patients normal neurological examination and lack of radicular symptoms or history of malignancy or trauma, the MRI study of the lumbar spine was not medically necessary for evaluation of this patients condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for claviculectomy, acromioplasty, and rotator cuff repair. In this case, the patient presents with left shoulder subacromial impingement, acromioclavicular arthrosis, and biceps tenodesis. Progress notes documented extreme pain, which is affecting her overall health due to her lack of sleep. Focused physical examination of the left shoulder revealed full active range of motion and pain with overhead reaching. The patient also has positive Hawkins, Neers, and OBriens signs. There is good strength with rotator cuff testing. Tenderness to palpation is noted at the biceps groove. History and physical examination, with MRI findings support a significant persistent impingement syndrome, partial and even possible full thickness cuff tear affecting activities of daily living. There is pain noted with overhead reaching and nocturnally. The provider documented that the patient has failed a reasonable trial of conservative treatment modalities including activity modification, medications. For these reasons, the requested claviculectomy, acromioplasty, and rotator cuff repair 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 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 parent of a 16-year-old male enrollee has requested authorization and coverage for a four (4) day inpatient stay for Thorazine infusions. Thorazine is a phenothiazine derivative which is primarily used for schizophrenia and occasionally for migraine. Per researchers, its mechanism of action as an analgesic in migraine is probably due to inhibition by Thorazine of the human pain threshold sodium channel. Medical literatures describe the use of Thorazine to abort migraine in children and adults in the emergency room. Researchers performed a retrospective cohort study of patients 12-21 years of age treated for migraine headache in their emergency department. Their study found that the most common adverse effect was hypotension (12%). The patient has tried and failed several treatments for chronic migraines. Records from the patients therapist indicate that the untreated pain has negatively impacted his mental health, with resulting conditions including depression and suicidal ideation. The treating pediatric headache specialist has now prescribed Thorazine injections. As noted above, Thorazine is indicated for treatment of migraines. Moreover, the four-day inpatient admission is necessary because the treating physician plans to administer Thorazine intravenously every 8 hours. This regimen would not be feasible in an infusion center, which would be closed at night. Additionally, due to the risk of hypotension, cardio-respiratory monitoring is necessary throughout the Thorazine administration. Thus, the requested four (4) day inpatient stay for Thorazine infusions is medically necessary for treatment of this patients chronic migraine headaches.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 neurology with a special qualification in child neurology, and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 34-year-old female enrollee has requested for exploratory laparotomy with possible hernia repair with preperitoneal mesh and computed tomography (CT) of the abdomen and pelvis for treatment of her inguinal hernia.  Findings:  The physician reviewer found that hernias can be subtle, particularly Spigelian and Trocar site hernias, and often are not appreciated on physical examination or cross-sectional imaging. This has resulted in differing opinions as to whether this patient in fact has a hernia. There is no confirmation of a hernia on imaging with computed tomography (CT) or magnetic resonance imaging (MRI), but the providers evaluation and review reported the presence of a hernia. In addition, if a hernia is found it should be repaired. Since additional imaging with CT is inadequate to diagnose and treat this patients condition, the requested surgery without the additional imaging has been shown to be medically necessary in this patients care.
Appeal type: Urgent Care
Decision: Overturned

A 45-year-old male enrollee has requested emergency services for treatment of his peri-rectal abscess. Findings:  The physician reviewer found that the disputed services meet prudent layperson criteria for emergency care given the totality of the patients circumstances. The patient had a large peri-rectal abscess which was incised, drained of copious pus, and packed with gauze on the first visit to the emergency department. The patient returned 48 hours later and the wound was noted to have a small amount of persistent drainage and was re-packed with gauze.  The patient returned 48 hours later for packing removal.  Patients who have undergone minor surgical procedures such as abscess drainage are often followed by the service that performed the procedure. Since the patients wound had previously been packed/repacked twice, it is to be expected that the patient would return to the emergency department on the date of service at issue for packing removal. The patient reasonably sought care in the emergency department to undergo packing removal as his primary care provider was not able to see him and the wound needed to be evaluated and the packing removed. For these reasons, the patients decision to seek treatment in the emergency department for the wound check/packing removal was reasonable and consistent with the response a prudent layperson would have under these circumstances.
Appeal type: Medical Necessity
Decision: Overturned

A 61-year-old female enrollee requested authorization and coverage of knee replacement surgery. The Health Plan denied the request indicating that the requested procedure is not medically necessary for treatment of the enrollees left knee pain.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plans denial on the basis that the requested procedure is medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

The patient has requested authorization and coverage for Humira 40 mg/0.8 ml weekly. The patient has been diagnosed with Crohns disease. Researchers reported that higher adalimumab levels are associated with biologic remission. An optimal level of greater than 8.5 g/mL was identified. Medical literature states that adalimumab concentrations greater than or equal to 12 g/mL were independently associated with endoscopic and histologic remission in Crohns disease. Researchers also reported that 40 mg adalimumab every other week or every week was superior to placebo for maintenance of clinical remission to week 54. In this case, the patient has undergone two operations and has had a recurrence of active disease revealed on recent colonoscopy. Per the records, the patient has been treated with Humira 40 mg every other week for approximately six months but is still having loose stools five to six times per day and two times overnight. The medical evidence supports the requested medication regimen in this clinical setting. Therefore, Humira 40 mg/0.8 ml weekly is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medication regimen 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.