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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for residential treatment services for the treatment of the enrollees behavioral health conditions. Findings:  The physician reviewer found that this patients substance use has been central to his daily routine and has been contributing to his significant impairment across multiple domains of functionality.  He began abusing drugs at the age of 10, which undoubtedly has compromised critical elements of psychological development such as identity formation.  Upon admission, he was addicted to multiple substances and was blacking out frequently.  He had difficulty holding down a job. He had no meaningful sober support network. The patient had previously failed outpatient drug treatment.  He also had co-occurring mental illnesses and a recent acute psychiatric hospitalization.  The patient was restless, agitated and anxious and had not completed his Suboxone taper.  The patient had a tense family session that evidenced a significantly strained support system. The patients appetite was suppressed, and his sleep was limited to three to five hours per night despite medication. The patient was experiencing anxiety, shakiness, flashbacks and poor concentration.  In sum, the services and setting were and are safe, appropriate and consistent with good practice. Additionally, the services provided were and are reasonably expected to improve the patients condition, prevent a more serious episode of illness and facilitate a seamless transition to comprehensive community-based programming.  Final Result: The reviewer determined that the services at issue were and are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in 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

Nature of Statutory Criteria/Case Summary: A female enrollee has requested reimbursement for fertility preservation services. Egg retrieval and egg and/or embryo freezing (cryopreservation) is a recognized option for women who have been diagnosed with cancer and who are undergoing treatment that can render them infertile. The medical evidence has shown that cancer treatment is toxic to ovaries/eggs. This option allows patients undergoing treatment to have children in the future. The goal of the procedure is to protect their gametes from the effect of the chemotherapy. This procedure is a treatment that is appropriate to offer to such patients. As noted in the medical literature, administration of gonadotoxic chemotherapy or radiation therapy often leads to infertility. Fertility preservation services, along with planning and intervention, have been proven to be an effective technique for preserving reproductive capacity. This treatment is supported by the American Society of Reproductive Medicine. In this patients case, when chemotherapy is anticipated to damage or destroy the womans eggs, such treatment is medically necessary. The American College of Obstetricians and Gynecologists also support fertility preservation treatment, noting, Based on the current state of evidence, modern procedures to cryopreserve oocytes should no longer be considered experimental.... Oocyte cryopreservation, with appropriate counseling, is recommended for patients facing infertility due to chemotherapy or other gonadotoxic therapies. For these reasons, the services rendered to this patient were medically necessary and a part of her cancer care. Accordingly, the preservation services were medically necessary for the treatment of this patients medical condition.Final Result: The reviewer determined that the services at issue were 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 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for 3D myelograms of the cervical, thoracic, and lumbar spine with contrast. The Health Plan has denied this request indicating that the requested service is not medically necessary for treatment of the enrollees hypermobile Ehlers Danlos syndrome, postural orthostatic tachycardia, and cerebral spinal fluid leak. At issue in this case is whether the requested 3D myelograms of the cervical, thoracic, and lumbar spine with contrast are medically necessary for treatment of the enrollees medical condition. The patient presents with the clinical criteria of a spontaneous cerebral spinal fluid leak. It is appropriate to discover the site of the leak, in order to repair the leak. This is done with 3D myelography. Therefore, the request for this service is medically necessary.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 neurological 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 74-year-old male enrollee has requested authorization and coverage for lumbar/sacral facet joint injection, for treatment of the enrollees low back pain.  Findings:  The physician reviewer found that the documentation available for review, lumbar/sacral facet joint injection are not medically necessary for treatment of this patients medical condition. Facet joint injections are not supported in the literature for treating radicular pain . In this case, the records report the patients radicular pain responded well in the past with these injections. However, there are no findings on recent documentation by the provider to support treatment of the patients radicular pain with a facet joint injection. All told, the requested authorization and coverage for lumbar/sacral facet joint injection, is not medically necessary for treatment of the patients medical condition.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 anesthesiology with sub-specialty certification in pain medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 54-year-old male enrollee has requested for diagnostic cardiac catheterization with coronary angiography and subsequent treatment for treatment of his medical condition. Findings:  The physician reviewer found that the likelihood of significant obstructive coronary disease is high, such that planning for possible percutaneous coronary intervention concomitant with a diagnostic coronary angiography is reasonable, appropriate and medically less risky compared to performing two separate procedures. Separate procedures may require two separate arterial access punctures which both carry an inherent increased risk; the alternative would be to utilize a shealth, which would be required to be maintained for several additional hours during transportation to a facility capable of performing percutaneous coronary intervention. Prolonged sheath placement would likely increase the rate of arterial access site complications such as infection or hematoma formation.  Also, if two separate procedures were required then additional catheter manipulation in the arterial system would likely result in an increased risk of catheter associated adverse events such as embolization. Therefore, it is medically reasonable, appropriate, less risky, and considered standard of care to expect elective cardiac catheterization to be performed in a facility that is also capable of performing percutaneous intervention in patients who have a high likelihood of needing such a procedure.
Appeal type: Experimental/Investigational
Decision: Upheld

A fifty-two year old male with severe hip arthritis is requesting authorization of a hip resurfacing arthroplasty.  The patient has had chronic pain that is not alleviated by standard therapeutic interventions.Reviewers Findings:One of the physician reviewers found that hip resurfacing arthroplasty is an alternative to traditional total joint arthroplasty and is currently promoted to be indicated in younger, more active patients with osteoarthritis such as this patient. As such, hip resurfacing arthroplasty is a medically reasonable and appropriate treatment option in this case.  This reviewer found that the Health Plan denial should be overturned. Two of the physician reviewers found that the efficacy of the procedure in question remains unproven.  There are no long-term prospective studies that show hip resurfacing arthroplasty has clear benefit over traditional hip replacement procedures and the extent of the related risks is still unknown.  These two reviewers found that the Health Plan denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Gammagard infusions 60 grams every four weeks. This patients records document small fiber neuropathy, which the provider noted is likely due to Sjogrens. The provider has recommended treatment with Gammagard infusions. There is a lack of prospective randomized controlled clinical studies demonstrating the long-term safety and efficacy of intravenous immunoglobulin (IVIG) for the treatment of patients with small fiber neuropathy. Gaillet and colleagues reported data suggesting that IVIG treatment can be effective and well-tolerated in patients with small fiber neuropathy. However, the authors concluded that their findings have to be confirmed in a randomized double-blinded placebo-controlled trial. IVIG has been approved by the U.S. Food and Drug Administration (FDA) for the treatment of chronic inflammatory demyelinating polyneuropathy based on large controlled studies confirming the short- and long-term safety and efficacy. There is an absence of adequate data showing positive health outcomes and minimal adverse effects with IVIG for small fiber neuropathy. Standard therapies such as gabapentin and tricyclic antidepressants have been shown to reduce pain associated with polyneuropathy with minimal side effects. This patients records do not document that the patient has exhausted the standard of care medications for treatment of small fiber neuropathy. For these reasons, the requested Gammagard infusions 60 grams every four weeks are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings:  Two of the three physician reviewers found the requested Gammagard infusions 60 grams every four weeks are 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 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 reviewer 1 is board certified in neurology with subspecialty certification in vascular neurology and is actively practicing. Physician reviewer 2 is board certified in neurology with subspecialty certification in neuromuscular medicine and is actively practicing. Physician reviewer 3 is board certified in neurology 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: Experimental/Investigational
Decision: Upheld

Physician 1: This patient is a 41-year-old male who has degenerative disc disease at L4-5 with resultant back pain and radiculopathy. A laminectomy and laminotomy performed in 1997 has not provided enduring pain relief. His physician indicated that the patient has tried conservative measures and is unable to relieve his pain. Therefore, the patient is requesting an artificial disc replacement.  This procedure has been denied by the Health Plan because it is considered experimental.The Health Plan is correct that the proposed procedure is considered experimental. There is no evidence to support disc replacement surgery for this patient. The proposed procedure is still under investigation and is not considered standard of care. The long-term success rate and safety profile remain unknown. Furthermore, based upon the clinical information provided, artificial disc replacement is contraindicated in this patient given his history of previous lumbar disc surgery. For these reasons, I have determined the requested procedure 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.Physician 2: The patient is a 41-year-old male with degenerative disc disease at L4-5. The patient has failed conservative therapy. His provider is recommending artificial disc replacement surgery. The Health Plan considers this procedure experimental.The proposed procedure is experimental without established long-term safety and efficacy. Available data does not demonstrate an advantage to disc replacement over fusion. The long-term safety profile is unknown. There is no clinical indication demonstrating the proposed procedure is the best treatment option for this patient. There are other treatments available. For these reasons, I have determined the requested procedure 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.Physician 3: The patient is a 41-year-old male with degenerative disc disease at L4-5. The patient has failed conservative therapy. His provider is recommending artificial disc replacement utilizing the artificial disc. The Health Plan considers this procedure experimental.The current clinical evidence regarding the artificial disc has allowed for Food and Drug Administration (FDA) approval that it is not inferior compared to fusion. Similarly, current studies appear to indicate it is not worse than fusion. Additional claims of efficacy are based upon a small number of short-term, non-randomized studies. A 300 patient FDA regulated investigational device exemption trial with long-term follow-up is underway. Without the results of this trial, artificial disc replacement remains experimental. Furthermore, it is not established as superior to fusion. Therefore, I have determined the requested procedure is 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested daily outpatient skilled rehabilitation services for treatment of her medical condition. Findings: The physician reviewer found that based on the documentation submitted for review, daily outpatient skilled rehabilitation services provided have not been established as medically necessary. The patients functional mobility and self-care were at a level that did not require additional skilled intervention. A home exercise program and outpatient care of a physiatrist were sufficient. The patient did continue to have language deficits. A review of speech and language therapy (SLT) following stroke by reviewers concluded that Our review provides some evidence of the effectiveness of SLT for people with aphasia following stroke in terms of improved functional communication, receptive and expressive language. This review included studies that compared SLT to social support or stimulation (an intervention that provides social support and communication stimulation but does not include targeted therapeutic interventions). The authors found that More participants also withdrew from social support than SLT interventions. Based on this review, SLT appears to have some degree of efficacy in the treatment of aphasia secondary to stroke. However, there is a lack of support for a specific duration of therapy. In this case, the patient was treated with intensive speech therapy. The medical literature does not show that further intensive speech therapy is medically necessary in this clinical setting. Given the above, the services at issue were not and are not medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the services at issue were not and 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 physical medicine and rehabilitation with sub-specialty certification in neuromuscular medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 42-year-old female enrollee requested authorization and coverage of a transphenoidal craniotomy through a neuroscopic binocular approach. The Health Plan denied the request indicating that the requested procedure is not medically necessary for treatment of the enrollees pituitary macroadenoma.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested services are not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

A 39-year-old female enrollee has requested laparoscopic duodenal switch surgery for the treatment of her morbid obesity. Findings:  The physician reviewer found that this patient meets the guidelines set by National Institutes of Health for the treatment of morbid obesity with surgery. The American Society of Metabolic and Bariatric Surgery identified the duodenal switch operation as an option for the patient. The Health Plans reference does not objectively compare the two procedures. Gastric bypass patients do have significant nutritional deficiencies that are not present in duodenal switch patients. One example is Wernicke encephalopathy. After gastric bypass, patients have a high incidence of dumping syndrome, marginal ulcers and protein deficiencies. Although a duodenal switch operation may also result in nutritional deficiencies, the postoperative diet for a duodenal switch patient is much more normal since the anatomy of the stomach is reduced in a physiological way allowing proper functioning of its regulatory mechanisms. This patient should be offered the duodenal switch operation, since it has better long-term outcomes when it comes to the percentage of excess body weight loss.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: A 45-year-old female enrollee has requested authorization and coverage for a refill of Norco for treatment of the enrollees pain.  Findings:  The physician reviewer found that The submitted documentation fails to demonstrate the medical necessity of the requested medication. Guidelines offer specific requirements for the ongoing use of opiate pain medication to treat chronic pain. Per the current guidelines, the lowest possible dose should be used. Additionally, providers should document the patients response to pain medication, including the duration of symptomatic relief, functional improvements, and the level of pain relief with the medications.  In this patients case, it is not clear that the use of the prescribed opioid medication  decreased the level of pain the patient reported from one visit to the next. In addition, there was no noted functional improvement noted. The current medical evidence does not support the requested medication in this clinical setting. All told, the requested refill of Norco is not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in neurology with sub-specialty certification in pain medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary:   An enrollee has requested Prometheus Anser IFX testing (serum infliximab and antibodies to infliximab) for evaluation of his medical condition.   Three physician reviewers found that the submitted documentation fails to demonstrate the superior efficacy of the services at issue.  The records do not indicate that Anser IFX testing was needed in the management of this patient.  Although there may have been concern that he was developing a lupus-like syndrome from his anti-tumor necrosis factor drug, the appropriate testing in this setting would have been a serum anti-nuclear antibody and anti-histone antibody.  All told, the services at issue were not likely to have been of greater benefit than other methods of evaluating this patient. Final Result: Three reviewers determined that the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: All three reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology 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.