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

A 36-year-old female enrollee requested residential treatment for treatment of her schizoaffective disorder and substance abuse.  Findings:  The physician reviewer found that generally accepted standards of care state that residential treatment is reserved for patients with substance use disorders or mental disorders such as schizoaffective disorder that are dangerous to themselves or others due to suicidal or homicidal ideation (Sharfstein). As noted in the review by McCarty and colleagues, intensive outpatient treatment programs are as effective as inpatient treatment for most individuals. Facility records indicate that this patient denied suicidal and homicidal ideation at admission. Moreover, facility records show that the patient denied suicidal and homicidal ideation throughout the residential stay. The providers records do not support an indication for treatment at the residential level of care for this patient. Moreover, the records do not explain why residential level of care continued to be needed for this patient during the stay. Overall, the patient could have been safely and effectively treated in a less restrictive level of care. For these reasons, residential treatment services were not and are not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 53-year-old female enrollee has requested a repeat treatment with Synvisc injections for treatment of her knee pain. Findings:  The physician reviewer found that viscosupplementation for knee osteoarthritis has been generally accepted as part of the treatment of osteoarthritis of the knee, with modest, short-term reduction in pain and improvements in function. However, there is need for prospective, controlled, double-blind studies to evaluate effectiveness, and some studies have raised questions as to the efficacy of the procedure. There is evidence that the benefits are greater in cases of non-radiologically severe osteoarthritis. There is some evidence that repeated courses of treatment may be beneficial, but the available evidence is not sufficient to reach firm conclusions on the effect of multiple courses of treatment. Studies are in progress to evaluate this question, but the results are not yet available.  The current medical evidence does not support the requested services in this clinical scenario at this time. All told, the requested repeat treatment with Synvisc injections is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

A thirty-five year-old obese female with multiple comorbid conditions is requesting authorization for Lap-Band surgery.  Reviewers Findings:  The reviewing physician found that Pending successful psychological evaluation, the patient is a suitable candidate for Lap-Band surgery.  The reviewing physician found that the Health Plan denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Overturned

A 44-year-old female enrollee has requested ultrasound treatment (ultrasound bone growth stimulation) for her fracture. Findings:  Two physician reviewers found that in this patients case, the requested services are likely to be superior over other available treatment modalities.  This patient smokes one pack of cigarettes per day.  This places the patient at high risk for a non-union of her fracture.  The current medical evidence supports the requested services in this clinical setting.  In this case, the application of a bone growth stimulator would be more beneficial than immobilization alone.  All told, the requested ultrasound treatment (ultrasound bone growth stimulation) is likely to be of greater benefit than other available treatment options.
Appeal type: Experimental/Investigational
Decision: Overturned

An enrollee has requested authorization and coverage for MaterniT21 Plus. The use of a specific cell-free DNA test focuses on an individual patients needs as well as personal and family history. For detection of chromosomal aneuploidies 13, 18 and 21, MaterniT21 testing is indicated for this patient. The records document abnormal findings on ultrasound. The American College of Obstetricians and Gynecologists (ACOG) noted that cell-free DNA testing is not recommended as a routine, first-line test. However, given the presence of a higher risk of fetal aneuploidy in this case, the requested MaterniT21 Plus is likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Findings:  Two of the three physician reviewers found the requested MaterniT21 Plus is likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested services are likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewers 1, 2, and 3 are board certified in obstetrics and gynecology 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested bilateral occipital nerve block and trigger point injections performed for treatment of her intractable chronic migraine.  Findings:  Three reviewers found that the records do not indicate the presence of occipital neuralgia as documented by physical examination findings. Occipital nerve blocks are not supported for the treatment of migraine or other type headaches. Cuadrado and colleagues noted there was no long-term improvement of headache of chronic migraine type with use of occipital nerve block.  The study by Dilli and colleagues noted greater occipital nerve block do not reduce the frequency of moderate to severe migraine days in patients with episodic or chronic migraine compared to placebo.  The medical records do not indicate occipital nerve block and trigger point injections were indicated for the treatment of this patients migraine headache condition. Thus, the superior efficacy of bilateral occipital nerve block and trigger point injections performed  has not been demonstrated.  Final Result:  Three reviewers determined that the services at issue were 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: All three reviewers are board certified in neurology 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: Overturned

A 43-year-old male enrollee has requested bariatric surgery for treatment of the enrollees obesity.  Findings:  The physician reviewer found that this denial is based upon the belief that compliance with a preoperative program is correlated with compliance with a postoperative program, as there is the need for dietary modification after restrictive bariatric operations.  However, recent studies have failed to document this correlation.  Recent studies have indicated that patients who did not participate in preoperative medically-supervised weight loss programs were just as likely to lose weight after bariatric procedures as patients who did participate in these programs.  The Health Plans preoperative requirement for bariatric surgery is not required to obtain optimal outcomes from surgery.  All told, the requested bariatric surgery is medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for behavioral therapy, occupational therapy and speech therapy. Findings:  The physician reviewer found that, according to Centers for Disease Control and Prevention (CDC) on the diagnosis of autism, There are many tools to assess ASD in young children, but no single tool should be used as the basis for diagnosis. Diagnostic tools usually rely on two main sources of information-parents or caregivers descriptions of their childs development and a professionals observation of the childs behavior. Although no single tool should be utilized, there are several autism specific evaluation tools available such as the Autism Diagnostic Observation Schedule (ADOS) and the Childhood Autism Rating Scale. In this case, it does not appear that a valid autism screening test was utilized. While the GADS was clinically useful in the past, the diagnosis of Aspergers disorder no longer exists with Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-V) criteria. This fact, coupled with age appropriate skills in cognition/general ability, academic skills, language, motor skills and social-emotional function make the diagnosis of autism unlikely. In addition, the in-Plan records from the multidisciplinary evaluation were not consistent with an ASD. The patients speech and occupational therapy assessments demonstrated an alert and interactive child who does not qualify for speech or occupational services. Based on the documentation submitted for review, the request for behavioral therapy, occupational therapy and speech therapy have not been established as 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 physician reviewer is board certified in pediatrics with sub-specialty certification in developmental and behavioral pediatrics 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 sclerotherapy injections.Submitted documentation supports that sclerotherapy injections are partially medically necessary. Medical literature shows that care of patients with varicose veins of the lower limbs and pelvis. SVS/AVF clinical practice guidelines recommend liquid or foam sclerotherapy for telangiectasia, reticular veins, and varicose veins (SVS/AVF guidelines, Recommendation 12.1). Accordingly, sclerotherapy injections to the non-axial veins is medically necessary to treat the patients medical condition. Sclerotherapy injections to the major axial veins, however, is not medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested services are partially medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned.Credentials/Qualifications: The reviewer is board certified in surgery, with primary specialty certification in vascular 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 43-year-old male enrollee has requested Lexapro for treatment of his behavioral health condition. Findings:  The physician reviewer found that this patient has a history of depression and apparently has responded to Lexapro, but there is no indication that he has been tried on one or more of the numerous medications on the Health Plans formulary. According to American Psychiatric Association practice guidelines, there are numerous antidepressants available in this clinical setting and there is not strong evidence that Lexapro is any more effective than any of the formulary medications. For instance, Celexa (a formulary medication) is very similar chemically to Lexapro and should be able to be substituted without any adverse consequence to the patient.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patients parent has requested reimbursement for neuropsychological testing services including: (1 hour of 96132; 1.5 hours of 96133); (1 hour of 96116; 1 hour of 96121; 0.5 hour of 96136; 1 hour of 96137); (4 hours of 96137); (2 hours of 96137); (2 hours of 96133); (1 hour of 96133); and (1 hour of 96133). Neuropsychological testing is a key diagnostic tool for assessing patients with dementia and mild cognitive impairment, as well as other neurological conditions such as Parkinsons disease, stroke, multiple sclerosis, traumatic brain injury, and epilepsy. In the pediatric population, neuropsychologic assessments are used to evaluate developmental delays in addition to cognitive, behavioral, sensory-motor, perceptual, and socio-affective functioning skills. As noted in the medical literature ADHD, anxiety disorders, depression, and social disorder are clinical diagnoses that do not require confirmation via neuropsychological testing (Husser, et al.; Wolraich, et al.). According to the records provided for review, this patient was previously diagnosed with ADHD, inattentive presentation, in 2018. The provider noted that the patient was experiencing stressors, which contributed to his anxiety and depressive symptoms. In this clinical setting, a comprehensive psychiatric evaluation and utilization of various self, parent, and teacher rating scales would have been adequate for evaluation and treatment of this patient. For the reasons outlined, the neuropsychological testing services including: (1 hour of 96132; 1.5 hours of 96133); (1 hour of 96116; 1 hour of 96121; 0.5 hour of 96136; 1 hour of 96137); (4 hours of 96137); (2 hours of 96137); (2 hours of 96133); (1 hour of 96133); and (1 hour of 96133) were not medically necessary for this patient. Final Result: The reviewer determined that the services at issue were not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in psychiatry with subspecialty 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: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for estrogen cream compounded with Aquaphor ointment 41%. The Health Plan has denied this request indicating that the medication is not medically necessary for treatment of the enrollees vaginitis and vulvovaginitis.The patient reported that she needs a compounded product using Aquaphor as carrier medium to treat her symptoms of vaginal pain and irritation.  However, the medical records do not document that the patient has tried and failed standard treatments.  Per the U.S. Food and Drug Administration (FDA) recommendations, compounded products should be reserved for patients who have demonstrated failure of FDA approved products and for which there is no alternative.  In this case, there is limited data to support the superiority of compounded estrogen preparations.  Per the medical evidence, there is an uncertainty as to the purity and potency of such products. Therefore, the requested estrogen cream compounded with Aquaphor ointment 41% is not medically necessary for the 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 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: Experimental/Investigational
Decision: Overturned

A 41-year-old female has requested BRCA1 and BRCA2 genetic testing.  Findings:  Three physician reviewers found that the patient does not have a history of breast cancer.  She has a paternal aunt with breast and ovarian cancer.  A cousin (daughter of the affected aunt) tested positive for BRCA mutation and is status post bilateral mastectomy and total abdominal hysterectomy with bilateral salpingo-oophorectomy. The patients sister had breast cancer at the age of 50 and is status post bilateral mastectomy.  The patient has had suspicious mammograms, and a recent biopsy showed focal atypia.  BRCA testing is important in clinical oncology because bilateral mastectomy would reduce a carriers chance of developing breast cancer.  Likewise, closer surveillance for ovarian cancer can be applied or the patient may choose salpingo-oophorectomy, which would reduce the probability of developing this cancer.  At the present time, genetic testing is not applied universally, but rather is recommended for patients with family histories that are suggestive of inherited predispositions.  In this patients case, she has one second-degree relative with breast cancer and ovarian cancer.  Additionally, she has a first-degree relative with breast cancer.  There is sufficient evidence to test this patient for BRCA1 and BRCA2 mutations.  All told, the requested BRCA1 and BRCA2 genetic testing is likely to be more effective than other tools for evaluating this patient.
Appeal type: Medical Necessity
Decision: Overturned

A 40-year-old female enrollee has requested Provigil for treatment of her major depressive disorder and post-traumatic stress disorder (PTSD). Findings:  The physician reviewer found that while it is true that the FDA has not approved Provigil for the treatment of major depressive disorder, adequate medical literature is available to demonstrate the utility of the drug for the treatment of this condition. Review of the relevant medical literature reveals three open-label trials suggesting modafinil's efficacy as an augmentation to antidepressants (DeBattista et al. 2001; Menza et al. 2000; Ninan et al. 2004) or as a way to help ameliorate the sedation caused by antidepressants (Schwartz et al. 2004). A small, preliminary controlled trial (DeBattista et al. 2003) found modafinil effective for the fatigue associated with depression. Each of these references comes from established journals that are accepted by practicing psychiatrists. It is a relatively frequent and accepted practice to augment antidepressants with stimulants such as Provigil.
Appeal type: Medical Necessity
Decision: Upheld

A 65-year-old male enrollee requested authorization and coverage of thalidomide. The Health Plan denied the request indicating that the requested medication is not medically necessary for treatment of the enrollees recurrent malignant melanoma.Three physician reviewers performed a medical necessity Independent Medical Review. Two of the three physician reviewers concluded that the requested medication is not medically necessary for treatment of the enrollee's medical condition. One of the three physician reviewers concluded that the requested medication is medically necessary for treatment of the enrollee's medical condition. Because two of the three physician reviewers concluded that the requested medication is not medically necessary for treatment of your medical condition, the Health Plans denial was upheld.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for genioplasty with two or more sliding osteotomies and an osteoplasty facial bones augmentation. The World Professional Association for Transgender Health (WPATH) lists facial feminization surgery as a medically necessary treatment for gender dysphoria. WPATH notes that for certain patients, surgical procedures such as facial feminization surgery can have a radical and permanent effect on their quality of life. In this case, the patient has a diagnosis of gender dysphoria and the provider has recommended facial feminization surgery. There is sufficient support for the requested service in this setting. Therefore, genioplasty with two or more sliding osteotomies and an osteoplasty facial bones augmentation 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 psychiatry with expertise in transgender health 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 39-year-old male enrollee has requested a plastic surgery consultation for treatment of his blepharitis.  Findings:  The physician reviewer found that based on review of the available records, this patient complains of chronic blepharitis and blepharochalasis. He reports that two ophthalmologists have been unable to diagnose his condition, but the case summary notes indicate that his most recent ophthalmology examination was in 2010. Ophthalmology notes from prior visits are not provided for review. Blepharoplasty is not an appropriate treatment for blepharitis and is not an appropriate treatment for a patient who has unexplained eye swelling and who has not yet had a comprehensive ophthalmologic examination. While a plastic surgeon can remove excess eyelid skin, a plastic surgeon is not trained in the evaluation and medical treatment of unexplained eyelid swelling. Without a diagnosis, blepharoplasty is contraindicated, and a plastic surgeon is not the appropriate specialist for referral to diagnose eyelid swelling. Therefore, the requested referral to a plastic surgeon for evaluation is not medically necessary for this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 62-year-old female enrollee has requested surgery using NanoKnife procedure for treatment of her colon cancer with liver metastases.  Findings:  The physician reviewer found that NanoKnife is a promising form of ablative technology which may improve upon current modalities. However, there is currently inadequate data to support its use outside of a clinical trial or institutional protocol. The records provided for review do not document that this patient has exhausted all non-surgical options. She may be a candidate for chemoembolization, spheres, or intensity modulated radiation therapy (IMRT), which have been proven more effective for treatment of metastatic disease.