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

Nature of Statutory Criteria/Case Summary: The parent of a male enrollee has requested reimbursement for the genetic testing (CPT 81229). The American College of Medical Genetics, the American Academy of Pediatrics, and the American Academy of Neurology all recommend chromosome microarray as the first-line in the evaluation of children with global development delay. Moreover, there is ample data in the published medical literature demonstrating the clinical utility of chromosome microarray in the evaluation of young patients with global developmental delay or autism spectrum disorder. Given this support, the genetic testing (CPT 81229) was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Findings:  Three physician reviewers found the genetic testing (CPT 81229) was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the genetic testing (CPT 81229) was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Credentials/Qualifications: Physician reviewer 1 is board certified in pediatrics and are actively practicing. Physician reviewer 1 is board certified in pediatrics and neurology with special qualification in child neurology and are actively practicing. Physician reviewer 1 is board certified in pediatrics with subspecialty certifications in neurodevelopmental behavioral pediatrics and genetics 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: The patients parent has requested authorization and coverage for general anesthesia (CPT 00170 and 41899) for dental procedures. The American Academy of Pediatric Dentistry states that indications for general anesthesia include patients who cannot cooperate due to a lack of psychological or emotional maturity and/or mental, physical, or medical disability. The American Dental Association (ADA) supports deep sedation or general anesthesia for mentally or physically challenged patients (Cote, et al.). In this case, the patient requires placement of amalgam fillings, resin, and therapeutic pulpectomy. However, there is a lack of documentation from the providers to support an indication for general anesthesia for the performance of these procedures. There is no documentation of previous difficulty with dental procedures. In addition, the records do not state that the patient has other medical or behavioral health conditions, which would require general anesthesia in order to complete the proposed dental procedures. Moreover, the providers did not report that there were previous attempts to complete the proposed dental procedures in an office setting. All told, the requested general anesthesia (CPT 00170 and 41899) for dental procedures is not medically necessary for 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.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the transcranial magnetic stimulation (TMS). As noted in the medical literature, TMS is a non-invasive, neuro-stimulatory intervention endorsed by the American Psychiatric Association (APA) for the treatment of acute phase depression in the adult population. A typical treatment course of TMS consists of 30-40 sessions over four to six weeks. Researchers noted that controlled studies of longer duration, acute treatment courses or using alternative treatment parameters are not established. The researchers also noted that an extended treatment course of one to two weeks may be appropriate for patients who experience only partial improvement and the clinician believes that a clear plateau of benefit has not been obtained. However, based on the records provided for review, the patient had already utilized this additional time frame. Given the lack of adequately powered, controlled studies showing the benefit of longer courses of TMS therapy, the TMS therapy services provided on were not medically necessary for treatment of this patients medical condition. 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

Nature of Statutory Criteria/Case Summary: The enrollee has requested reimbursement for intensive outpatient program (IOP) services received. The Health Plan has denied the services at issue as not medically necessary.The American Society of Addiction Medicine (ASAM) criteria describe the continuum of treatment for patients seeking recovery from alcohol dependence. In reviewing the ASAM criteria, the patient had minimal medical complications or withdrawal symptoms. He had mild behavioral complications, he was cooperative and ready for change yet required the structure and monitoring given his high relapse potential. His recovery environment was moderately supportive, but he had no partner or close family involvement. He admitted that people in his support system used alcohol. Based on the ASAM criteria, the patient met the criteria for IOP during the period at issue. 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 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 reimbursement for laboratory testing (CPT 82523 collagen crosslinks) provided 3/06/21 by Quest Diagnostics. Findings:  The physician reviewer found that The use of markers of bone turnover is standard practice among endocrinologists and other specialists in osteoporosis and is cited as a tool to monitor therapy in the recent Endocrine Society guidelines for the management of osteoporosis. Collagen crosslinks are bone turnover markers that are used as a guide to monitor compliance and efficacy of treatment. They also help to identify non-responders that require additional work-up for other causes of osteoporosis. Lorentzon and colleagues found that the currently available evidence indicates that the principal clinical utility of bone turnover markers is for monitoring therapy. In this case, the patient's endocrinologist used the information from the collagen crosslink test result to determine whether patient was responding to therapy after 6 months of therapy with Fosamax, a bisphosphonate, which is antiresorptive. Therefore, laboratory testing (CPT 82523 collagen crosslinks) provided 3/06/21 by Quest Diagnostics was likely to have been more beneficial for evaluation of the patients condition than any available standard therapy.Final Result: The reviewers determined that the service at issue was likely to have been more beneficial than any available standard method of evaluation for the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewers 1, 2, and 3 are board certified in internal medicine with sub-specialty certification in endocrinology, diabetes, and metabolism 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. Findings: Two out of three physician reviewers found that laboratory testing (CPT 82523 collagen crosslinks) provided 3/06/21 by Quest Diagnostics was likely to be more beneficial for you than any available standard therapy .
Appeal type: Medical Necessity
Decision: Upheld

A 46-year-old male enrollee has requested authorization and coverage of varicose vein stripping and ligation. The Health Plan denied the request indicating that the procedure is not medically necessary for treatment of the enrollees varicose veins.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested procedure is not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 43-year-old female who has a history of depression and alcohol abuse. She began inpatient hospitalization in 2005. At the time of her admission, the patient was suicidal as evidenced by an emergency room visit secondary to taking excessive Xanax and alcohol. In the psychiatric history and evaluation, the patients chief complaint was constant thoughts of not wanting to be around. A request has been made for coverage for continued inpatient psychiatric treatment services. The Health Plan indicates the submitted documentation does not demonstrate the requested services are medically necessary.Although the patient had symptoms consistent with active suicidality upon admission, these symptoms were most likely precipitated or exacerbated by active alcohol intoxication. There is scant evidence in the medical record to suggest ongoing suicidality. It would have been medically reasonable and appropriate to transfer the patient to partial hospitalization or outpatient chemical dependency program, at which point the patient was stable. There is no evidence of acute alcohol withdrawal symptoms at the time of admission. Detoxification was optimal and certainly could have been completed. Therefore, I have determined that inpatient psychiatric treatment services were medically necessary. The Health Plans denial should be partially overturned.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 44-year-old male with recurrent prostatitis with apparent flare-up, including symptoms of dysuria. The patient was treated with Cipro. In 2003, the patient had perineal aching radiating to his penis, groin, and right testis with post-void discomfort, worse after sexual intercourse. There were findings of myofascial pelvic floor pain with tender pudendal nerve. Electrodiagnostic testing revealed prolonged latency (conduction time) of the left pudendal nerve, consistent with the diagnosis of pudendal nerve entrapment. A report from the patients treating physician indicated the patient responded well to physical therapy and pudendal nerve blocks, but still had some nerve sensitivity. The patient continued to receive electromyography biofeedback therapy and physical therapy services from his provider at least until 2004. The patient has requested reimbursement for these services. The Health Plan has denied the request indicating that the services at issue were not medically necessary.The patient has had chronic pelvic pain syndrome, a condition of sometimes vague causation and one that is often difficult to treat effectively. One cause for the problem is prostatitis, which the patient had apparently had for many years. The patients urological evaluation is not documented. The patient also has documented pudendal nerve entrapment. Review of the submitted records indicates the patients condition was appropriately treated with the course of pudendal nerve block injections that he received. There is no objective medical evidence that physical therapy or biofeedback had any significant effect on the patients condition. Based upon the information provided, there was no clinical indication for continued services. Therefore, I have determined that the services at issue were not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Trulicity 3 mg/0.5 mL. Trulicity is a member of a class of diabetic medications, the glucagon like peptide-1 receptor agonists (GLP-1RA). The GLP-1RA medications help regulate insulin secretion in proportion to environmental glucose levels and may also have beneficial effects on the cardiorenal system including reducing cardiovascular risk and improving renal outcomes. Given the effectiveness for hemoglobin A1C reduction, GLP-1RA agents are recommended as the preferred injectable glucose-lowering therapy for patients with type 2 diabetes, even before insulin treatment. The records provided for review document that this patient has responded well to Trulicity for the past three years. In addition, the provider noted that the patient did not achieve ideal glycemic control on other diabetes medications in the past including Actos and Byetta. Based on the provided documentation and the available peer-reviewed medical literature, the requested Trulicity 3 mg/0.5 mL is medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in internal medicine with subspecialty certification in diabetes, endocrinology, and metabolism 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 been diagnosed with right knee osteoarthritis. The patient reported right knee pain associated with clicking. The pain was noted to be exacerbated by sitting and climbing stairs. Physical examination findings included right knee patellofemoral and lateral joint line tenderness. The patient has previously been treated with right knee arthroscopic surgery, physical therapy, and nonsteroidal anti-inflammatory drugs. The provider noted an x-ray revealed degenerative changes in the patellofemoral and lateral compartments. The patient has requested authorization and coverage for Orthovisc injections. The Health Plan denied the request and reported that the requested services are not medically necessary for the treatment of this patient. At issue in this case is whether Orthovisc injections are medically necessary for the treatment of the patients medical condition. Review of the current medical literature pertaining to viscosupplementation reveals mixed results. Although viscosupplementation may relieve knee pain in some patients with osteoarthritis, it is unknown which patients will benefit. Considering the foregoing, viscosupplementation can only be recommended for patients with a history of lasting benefit from prior injections and in carefully selected cases when everything else has been tried and the options are limited. In this case, the patients options are limited. The patient has tried and failed other conservative treatments, with the alternative being a total knee arthroplasty. The medical evidence supports the requested services in this clinical setting. Therefore, Orthovisc injections 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 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

The patient is a 53-year-old female with a history of chronic fatigue syndrome, fibromyalgia, obstructive sleep apnea, arthritis, and chronic headaches. She has been tried on all anti-inflammatories, Risperdal, Zonegran, Prozac, and Diazepam without benefit. The patients current medication regimen includes Welbutrin, Effexor, Fiorinal, Ambien, Soma, and Nortriptyline. She continues to have fatigue and constant pain. The patient also is participating in a chronic fatigue group. Her primary care physician has recommended Provigil to help improve the patients energy. The Health Plan has denied authorization and coverage for Provigil on the basis it is not medically necessary for treatment of the patients medical condition. Based upon the submitted medical records, it does not appear the patient is currently responding to most of the medications that she has tried in the past. She does have obstructive sleep apnea as confirmed by sleep studies, which may contribute to her fatigue. Provigil has an excellent safety profile with minimal effects on the cardiovascular system. Given the failure of the patients previous and current treatment regimens, a trial of Provigil is medically reasonable and appropriate. Therefore, I have determined that the requested medication is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Overturned

A 60-year-old male enrollee has requested skin grafts (Acell MatriStem) for treatment of his neck and thigh wounds. Findings:  Two physician reviewers found that review of the submitted documentation and relevant literature supports the use of Acell MatriStem in this clinical setting. The patient presented with chronic non-healing wounds, which had failed to fully close with grafting. The treatment of Acell MatriStem was minimally burdensome with healing in a short amount of time. Moreover, a study by Lecheminant and Field conducted on patients who received urinary bladder matrix extracellular matrix (UBM) (MatriStem) concluded that UBM is effective in the treatment of acute and recalcitrant ulcerations when applied correctly with an appropriate dressing. In addition, of the 34 patients evaluated all patients treated with UBM progressed to full healing (Lecheminant and Field). All told, the use of Acell MatriStem was likely to be more beneficial for the treatment of the patients medical condition than other available options.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 52-year-old woman with a history of morbid obesity, diabetes mellitus, asthma, and osteoarthritis. The patient has poor coordination and has difficulty ambulating. She reports that she wears wrist braces. The patient has requested authorization for a power-operated vehicle (POV). The Health Plan indicates the submitted documentation does not demonstrate a POV is medically necessary for the patients mobility. The Health Plans denial should be upheld. Review of the submitted medical records fails to provide confirmation of any impairment, weakness or decreased range of motion involving the arms. Thus, the provided documentation does not demonstrate the patient is precluded from operating a manual wheelchair. Furthermore, the submitted medical records do not define the patients current ambulatory abilities. Hence, the medical necessity for a POV has not been established. Based upon the information set forth above, I have determined that the requested equipment is not medically necessary for the patients mobility. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

The enrollee is requesting reimbursement for residential treatment center (RTC) services. The enrollee has diagnoses of post-traumatic stress disorder, recurrent major depressive disorder without psychotic features, severe alcohol use disorder, severe other hallucinogen use disorder, severe cannabis use disorder, severe, unspecified stimulant use disorder, and severe sedative, hypnotic, or anxiolytic use disorder. The enrollee entered the residential treatment center for further evaluation and treatment of poly-substance use, emotional trauma, and progressively worsening depression and anxiety. She endorsed an inability to perform in her normal role functioning due to the severity of her substance use and psychiatric symptoms. The enrollee participated in her treatment plan and made meaningful progress during the hospitalization. She employed grounding techniques to learn to mitigate symptoms. She experienced fairly consistent levels of anxiety, most severe upon awakening, and she would improve as the day progressed. The Level of Care Utilization System (LOCUS) is a level of care assessment tool widely used by clinicians throughout the country to support accurate level of care recommendations. This tool was used in this review. The enrollees composite LOCUS score correlates with medically monitored residential level of care. Medical evidence supports the services at issue in this clinical setting.Final Result: The reviewer determined that the requested services were medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician 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 similar medical condition.