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

The patient is a 21-year-old female with a long and extensive history of psychiatric disorders including depression, anxiety, attention deficit disorder, obsessive-compulsive disorder and substance abuse. Her alcohol abuse began approximately nine months prior to admission. She had participated in outpatient psychotherapy with medication management, but had not been hospitalized in the past.  She was admitted for subacute psychiatric treatment in September 2005 and discharged in October 2005 with a plan for residential treatment. The Health Plan denied authorization for inpatient psychiatric services based upon their determination that the services were not medically necessary.The records from the psychiatric treatment facility are extremely detailed and include an extensive psychiatric evaluation, treatment plan (including goals and documented progress regarding attainment of goals), as well as a detailed discharge summary noting symptom improvement, prognosis and follow-up recommendations.  Given the well-documented chronic problems of this patient and worsening of her symptoms leading to admission at the facility, the admission and services rendered were clearly medically necessary and standard of care. Therefore, I have determined the services at issue were medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for computed tomography (CT) scan with contrast of the chest. Findings:  The physician reviewer found that For patients with pulmonary embolism (PE) that is unprovoked or in which risk factors cannot be reversed, lifelong anticoagulation is recommended. Follow-up imaging is not recommended, as resolution of the PE would not lead to a recommendation for discontinuation of anticoagulation as the threat of another life-threatening PE still exists. Guidelines do not endorse imaging in this clinical setting. In this case, the patient incurred an unprovoked saddle PE in August 2020. On 9/03/20, the pulmonologist recommended lifelong anticoagulation. Therefore, the requested CT scan with contrast of the chest is not medically necessary for the evaluation of the patients medical condition.Final Result: The reviewer determined that the requested service is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in hematology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 48-year-old female enrollee has requested authorization and coverage for a cervical artificial inter-vertebral disc (Pro-Disc C). The Health Plan has denied this request indicating that the requested procedure is considered investigational for treatment of the enrollees cervical disc extrusion.  Findings:  Three physician reviewers found that the patient has a left C7 radiculopathy due to a disc herniation at C6-7, as noted on her MRI scan. She has tried various forms of treatment with no long lasting relief. Her exam has been variable as noted by a neurosurgeon and orthopedic spine surgeon. She was found to have decreased sensation in a distal C7 distribution, atrophy of her triceps on her left side and mild weakness of her left triceps and finger extensors. No myelopathic findings were noted. The patients MRI scan also shows a large disc osteophyte complex at C5-6 on the right and a large disc herniation at C6-7 on the left. She was given the options of various forms of surgical treatment. Her surgeon proposes cervical artificial inter-vertebral disc (artificial disc replacement (ADR)) surgery with Pro-Disc C at C6-7.This patient clearly has left sided C7 radiculopathy due to a disc herniation at C6-7, which matches her MRI scan. She has been given various surgical options. ADR is proposed, however, she is not an appropriate candidate for ADR. One of the exclusions for ADR is adjacent segment degeneration. This is noted in the patients MRI at the C5-6 level. Additionally, the long-term safety and effectiveness of ADR with the Pro-Disc C has not been established. There are studies demonstrating the effectiveness of ADR (Delamarter, et al.; Murrey, et al.), but these and other available studies are small, not scientific, and have only short term follow up. There are no large, scientific long term follow up studies available. The Food and Drug Administration (FDA) has required a seven to ten year post approval study of Pro-Disc C to determine its long-term safety and effectiveness. This study is ongoing and has not been reported. Therefore, the Health Plans denial was appropriate and should be upheld.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for laboratory service (infectious disease, bacterial vaginosis and vaginitis, quantitative real-time amplification of DNA markers for Gardnerella vaginalis, Atopobium vaginae, Megasphaera type 1, bacterial vaginosis associated bacteria-2 (BVAB-2), and Lactobacillus species). Workowski and colleagues report that guidelines for sexually transmitted infection (STI) screening include female patients over age 25 with a sex partner with concurrent partners. The guidelines do not specify the method of testing recommended. In this case, notes reported that the patient requested screening for STIs due to concern regarding possible exposure from a recent partner. Given that the service at issue included laboratory testing containing components necessary for appropriate STI screening, it was likely to be more beneficial for the evaluation of the patient than not screening for STIs. Therefore, laboratory service (infectious disease, bacterial vaginosis and vaginitis, quantitative real-time amplification of DNA markers for Gardnerella vaginalis, Atopobium vaginae, Megasphaera type 1, bacterial vaginosis associated bacteria-2 (BVAB-2), and Lactobacillus species) was likely to have been more beneficial for evaluation of the patients condition than any available standard therapy.Findings:  Two of the three physician reviewers found the laboratory service (infectious disease, bacterial vaginosis and vaginitis, quantitative real-time amplification of DNA markers for Gardnerella vaginalis, Atopobium vaginae, Megasphaera type 1, bacterial vaginosis associated bacteria-2 (BVAB-2), and Lactobacillus species) at issue was likely to have been more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the service at issue was likely to have been more beneficial for treatment 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: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for bilateral Synvisc injections of knees. Findings:  The physician reviewer found that viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. The current evidence is limited, and guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate that the evidence is not conclusive. In light of the foregoing, viscosupplementation can only be recommended in individuals with a history of lasting benefit from prior injections, and in carefully selected cases where everything else has been tried, and the options are limited. In this case, the patient has a history of significant relief from prior injections. The patient has tried and failed other conservative treatments including cortisone injections. Given the patients limited options and based on the current medical literature, the requested services are medically indicated. Therefore, bilateral Synvisc injections of knees 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Saxenda.Obesity is associated with increased risk of multiple comorbidities. Few medications are currently available for the treatment of obesity, and their effectiveness and benefits often fade when the drugs are discontinued. Saxenda (liraglutide) may be prescribed for chronic weight management as an adjunct to a reduced-calorie diet and increased physical activity. Researchers noted, Data demonstrated that liraglutide can successfully achieve weight-loss benchmarks of 5% or more and 10% or more loss from baseline. In this case, the patient has struggled to lose weight despite a low calorie diet and regular exercise. Saxenda may assist this patient with losing weight and may have a positive effect in terms of her comorbidities related to her obesity, such as polycystic ovary syndrome. Thus, the Saxenda is medically necessary for the treatment of the patients condition.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 sub-specialty certification in endocrinology, diabetes 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: Upheld

A female enrollee requested Harvoni for medical treatment of her hepatitis C virus genotype 1a.   Findings:  Two physician reviewers found that the records provided for review document that this patient has minimal to no liver fibrosis. She is not immunosuppressed and demonstrates no extrahepatic manifestations of hepatitis C. The patient does not have concomitant liver diseases such as non-alcoholic fatty liver disease. Overall, her prognosis is excellent and there is a lack of clinical findings to support treatment with Harvoni. It is recommended to follow patients serially for evidence of progression using non-invasive markers of fibrosis such as Fibrospect II. All told, the requested Harvoni is not supported as medically necessary for treatment of this patients hepatitis C virus.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for bilateral facet joint injections at L2-3, L3-4 and L4-5. Most chronic back pain patients have both disc and facet joint disease. Findings:  The physician reviewer found that the patient most likely obtains relief of his radicular pain due to discogenic disease and stenosis from epidural injections, and he obtains axial back pain relief from facet joint injections. Per the guidelines, facet joint injections can be performed on a maximum of three levels in one sitting. Repeat facet joint injections may be appropriate if there is 50% improvement. In this patients case, he has a history of greater than 50% benefit from prior facet joint injections. Additionally, recent physical therapy has not been beneficial. Thus, there is sufficient support for the requested services in this clinical setting. Therefore, bilateral facet joint injections at L2-3, L3-4 and L4-5 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 anesthesiology with subspecialty 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: Medical Necessity
Decision: Upheld

The mother of an 18-year-old female enrollee requested authorization and coverage of breast augmentation surgery for treatment of the enrollees medical condition. The Health Plan denied the request indicating that the requested procedure is not medically necessary for treatment of the enrollees asymmetrical breasts.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 parent of a 9-month-old male enrollee has requested a molding helmet for the treatment of the enrollees plagiocephaly. Findings:  The physician reviewer found that this patient has brachycephaly with a minimal amount of plagiocephaly. He has failed standard treatment recommendations for positioning and tummy-time. The measurements taken of his head revealed a cephalic index of 97.5%, much greater than the norm, and clearly representative of significant brachycephaly. Based on the guidelines, a molding helmet is medically necessary and appropriate for this infant to prevent future complications and permanent deformity.
Appeal type: Medical Necessity
Decision: Overturned

The mother of a 19-year-old male enrollee requested authorization and coverage of home health care for treatment of the enrollees medical condition. The Health Plan denied the request indicating that the requested services are not medically necessary for treatment of the enrollees medical condition.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plans denial on the basis that 16 hours of home health care services a day are medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 39-year-old man with plantar fibromatosis. He has undergone prior procedures involving surgical excision of the masses. In May 2004, the patients provider indicated the patient had developed recurrent aggressive fibromatosis involving the right foot. The patients provider has recommended surgical excision of the right foot masses followed by radiation therapy. The Health Plan indicates the requested procedure is not medically necessary for treatment of the patients medical condition.The requested procedure is medically necessary for treatment of the patients right foot masses. As of May 2004, the patient had not developed a recurrence of masses in his left foot after undergoing surgical excision. It is medically reasonable to proceed with surgical excision of the right foot masses. The treatment as outlined by the patients provider is medically appropriate and is indicated at this time. Therefore, I have determined that the requested procedure is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

A 61-year-old female enrollee has requested an additional 12 visits of physical therapy for the treatment of her knee condition. Findings:  The physician reviewer found that this patient has had extensive skilled physical therapy (PT) visits and has improved functionally. Her right knee active range of motion (ROM) is 0-120 degrees. She is ambulating independently with a single point cane. She continues to have strength deficits and requires continued strengthening exercises. However, this deficit does not require the services and supervision of a skilled physical therapist. She can improve her right knee ROM, quadriceps and hamstring strength, and ability to climb stairs with a home exercise or gym program. It is not well documented in the physical therapy notes how the patients right leg strengthening was being accomplished, why her strength had not improved, and what would be done differently in the additional 12 visits of physical therapy being requested to ensure increased strength, ROM, and function of her right knee.
Appeal type: Medical Necessity
Decision: Overturned

A 21-year-old male enrollee has requested 15 hours per week of direct applied behavioral analysis (ABA) therapy (H2019); 2 hours per month of parent training (H0046) and 7 hours per month of supervision (H0032) for treatment of his autism spectrum disorder.  Findings:  The physician reviewer found that autism spectrum disorder (ASD) is a highly-comorbid neurodevelopmental condition firmly steeped in biological etiology. Applied behavior analysis (ABA) is an empirically proven treatment intervention for individuals diagnosed with ASD.  In this case, the requested 15 hours per week of one-on-one ABA services, 2 hours per month of parent training and 7 hours per month of supervision are likely to optimize his functionality in the community and minimize the potential need for services provided in more restrictive settings.  Based upon the documentation provided, the proposed services will be delivered in accordance with a comprehensive treatment plan that has quantifiable goals. In light of his persistent symptomatologys including aggressive behaviors, the requested ABA services are clinically indicated. In conclusion, based on his clinical presentation and relevant peer-reviewed literature, the requested 15 hours per week of one-on-one ABA therapy, 2 hours per month of parent training and 7 hours per month of supervision are medically appropriate and necessary for treatment of his medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for dialysis after 5:00 pm. Findings:  The physician reviewer found that there are potential complications that can occur during and immediately following dialysis including low blood pressure, fatigue, and prolonged bleeding, which can interfere with a patients ability to perform activities of daily living. In addition, many patients experience other symptoms following dialysis. As noted in the medical literature, noncompliance with dialysis has been associated with a poorer clinical outcome. A medical study dependably demonstrates substantially inferior health-related outcomes associated with missing treatments in hemodialysis patients. Moreover, mechanical difficulties with the dialysis machine itself are not infrequent, and can delay the time for dialysis to be completed. For a patient who continues to work while receiving dialysis, continued compliance requires a practical schedule using fourth shift dialysis (after 5:00 pm). This patients current dialysis schedule at 3:45 am interferes with his ability to perform activities of daily living and encourages noncompliance, which is associated with a poorer health outcome. Therefore, the requested dialysis after 5:00 pm is supported as medically necessary for treatment of this patients end stage renal disease (ESRD). 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 internal medicine with subspecialty certification in nephrology 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

An 18-year-old female enrollee has requested breast reconstruction surgery for treatment of her breast hypoplasia. Findings:  The physician reviewer found that the submitted documentation does not document whether there are congenital reasons for the lack of breast development. The submitted information does not document whether the patient has seen an endocrinologist to ascertain the etiology of her breast hypoplasia. Further evaluation is needed before the medical necessity of the requested procedure can be established.  This patients condition may be an abnormal development of the breast. However, in the absence of evidence of an endocrinology evaluation this cannot be confirmed.  This may be caused by a developmental abnormality, although the submitted documentation does not demonstrate this.  The requested surgery will create a normal appearance to the extent possible, and it may offer more than a minimal improvement in the appearance of the patient. However, at this time, additional evaluation is needed to demonstrate that the requested procedure is reconstructive in nature or medically necessary for this patient.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage consultation for bariatric surgery (gastric sleeve) for treatment of the enrollees obesity. Findings:  The physician reviewer found that the submitted documentation and medical literature demonstrate the medical necessity of the requested consultation. This patient is morbidly obese and may benefit from a bariatric procedure. The patient has made effort at non-surgical weight loss with her provider in the past. In addition, the patient previously obtained a bariatric consultation in 2016, and an updated consultation would be appropriate. Final Result: The reviewer determined that the requested consultation is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The physician 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.