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

Nature of Statutory Criteria/Case Summary: The patient has been diagnosed with primary female infertility. The submitted documentation reflects that the patient has attempted to become pregnant on two separate occasions by intrauterine insemination (IUI) in 2014 and 2016. These attempts included two IUI and nine IUI cycles, respectively. The patient has stated that she and her husband have been unable to conceive naturally and that IUI is the only thing that has worked for her. At issue in this case is whether infertility treatments (including CPT code 58323 for sperm preparation, CPT code 58322 for intrauterine insemination, CPT code 99214 for office visit, and CPT code 76830 for ultrasound) received from 12/07/18 forward were medically necessary to treat the patients medical conditionPatient age has a statistically measurable impact on pregnancy rates, and logistic regression analysis of intrauterine insemination (IUI) patients shows a drop in pregnancy rates with increasing age. Researchers reported that pregnancy rates for IUI patients aged 40 years remained stable even after more than three cycles, up until six cycles. Six cycles are considered a maximum to determine efficacy, as rates of pregnancy significantly decrease with increasing IUI use. Maternal age is the predominant factor in determining fertility in women with advanced maternal age. Success rates are exceedingly low with IUI in women after 40 years of age. A study revealed that in patients over 40, in vitro fertilization (IVF) should be considered after one failed IUI cycle. In this case, the patient has already undergone 12 total cycles of IUI with the last cycle in December of 2018, and she is now above the age of 40. Due to waning efficacy, and failure as defined by six cycles of IUI, further IUI cycles are unlikely to result in pregnancy. Thus, intracytoplasmic sperm injection (ICSI) or in vitro fertilization (IVF) should be considered. Under these circumstances, the infertility treatments (including CPT code 58323 for sperm preparation, CPT code 58322 for intrauterine insemination, CPT code 99214 for office visit, and CPT code 76830 for ultrasound) received from 12/07/18 forward were not and are not medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the requested services 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 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: Upheld

A 68-year-old male enrollee has requested prostate saturation biopsy for evaluation of his elevation of prostate specific antigen (PSA). Findings:  Two physician reviewers found that the records provided for review indicate this patient has a PSA of 14%, which is considered a low percentage of free PSA (less than 25%). The improved yield over 12 cores biopsy or clinical benefit in this setting has not been established in this clinical setting. Currently, transperineal template guided saturation biopsy of the prostate has not been shown to be as good as or better than transrectal ultrasound guided biopsy. Since this patient has already been evaluated with two prior biopsies, which were negative, the transperineal prostate biopsy performed on the date indicated was not likely to have been more beneficial for evaluation of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for all or any of the 30 sessions of TMS treatment provided by Manish Sheth, M.D., of Achieve TMS Centers. Current medical literature supports the use of TMS for severe, recurrent major depressive disorder that is unresponsive to medication management and psychotherapy treatment. Medical literatures note that multiple randomized controlled trials and published literature have supported the safety and efficacy of TMS antidepressant therapy in the treatment of major depressive disorder. Likewise, TMS is supported for the treatment of OCD that has not responded to other traditional treatments. The U.S. Food and Drug Administration (FDA) approves the use of the Brainsway Deep TMS System for the treatment of adult patients suffering from Obsessive-Compulsive Disorder. In a systematic review, researchers found that TMS was superior to sham stimulation for the amelioration of OCD symptoms. In this case, the records demonstrate that the patient has refractory OCD that has failed treatment with psychotherapy and medication management. Given that TMS was the clear next step in the treatment of this patients refractory OCD, the services at issue were medically indicated. In this patients case, TMS treatment was in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, the services at issue were clinically appropriate in terms of type, frequency, extent, site, and duration. The services at issue were not primarily for the economic benefit of the health care service plan and subscribers or for the convenience of the patient, treating physician, or other health care provider. Therefore, 30 sessions of TMS treatment provided by Manish Sheth, M.D., of Achieve TMS Centers were medically necessary for the treatment of this patient.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: Medical Necessity
Decision: Upheld

A 44-year-old male enrollee has requested an additional continuous positive airway pressure (CPAP) machine for the treatment of his sleep apnea. Findings:  The physician reviewer found that this patient clearly needs a CPAP machine for sleep apnea based on the number of events he experiences during sleep as well as his body habitus. However, to reduce his overall morbidity and mortality, it is not medically necessary to provide an additional CPAP device for his convenience of transportation to work. No study has shown that providing additional durable medical equipment devices improves compliance. In addition, the cited studies above support lack of compliance even when patients are at home. Short-term compliance predicts long-term compliance. A recent study demonstrated only age and use of a sedative improved compliance. Since the patient cannot use a sedative while at work, compliance is not likely to be increased even with a second unit.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patients parent has requested reimbursement and prospective authorization and coverage for direct applied behavioral analysis (ABA) services. According to researchers, medically necessary ABA services are (a) required to meet the essential health needs of the patient; (b) consistent with the diagnosis of the condition for which they are required; (c) consistent in type, frequency, and duration of treatment with scientifically based guidelines as determined by medical research; (d) required for purposes other than the convenience of the provider or the comfort of the patient; and (e) rendered in the least intensive setting that is appropriate for the delivery of health care. Using this definition, ABA services are medically necessary for this patient. ABA therapy has been identified as the most evidence-based treatment for patients with autism, thus ABA is required to meet the essential health needs of the patient. To address the issue of dosage, the Council for Autism Service Providers recently released updated practice guidelines for healthcare funders, which indicate that recommendations for treatment intensity should be made by a BCBA given their expertise and formal training specifically in ABA for the treatment of autism. The patients lack of progress is not a contraindication for additional therapy. Studies of ABA treatment intensity that support a dose-response relationship between intervention intensity and outcomes for a wide age range. A lack of progress towards goals does not contraindicate the need for more ABA therapy. The research indicates that additional hours of therapy are likely to benefit the patient and lead to better long-term outcomes in functioning. Moreover, given the patients high level of problematic and at-risk behaviors including aggression, self-injury, and elopement, a reduction in hours would likely lead to an increase in these behaviors over time. Further, the maintenance of goals already mastered is a key component to any ABA program and losing recommended therapy time will likely result in not only less goals mastered, but also loss of previously acquired skills for the patient. For these reasons, the requested direct ABA services were and are medically necessary for treatment of this patient. 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 a licensed B.C.B.A, board certified in psychology, 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 right T7-T8 epidural selective nerve block injections with monitored anesthesia care (MAC) for treatment of the enrollees back pain. Findings:  The physician reviewer found that review of the submitted documentation fails to support the medical necessity for the request for right T7-T8 epidural selective nerve block injections with MAC. In this case, the patient presents with thoracic pain. The documentation submitted for review fails to show physical examination findings of thoracic level radiculopathy such as segmental sensory loss or evidence of asymmetric abdominal reflex response or abdominal muscle weakness which could be assessed clinically by testing for Beevors sign. There is no imaging of the thoracic spine that corroborates a diagnosis of thoracic level radiculopathy. In addition, the patient was referred for physical therapy and Topamax appears to have been started which does not reflect a failure of conservative treatments. The duration of symptoms as well as pain severity are not documented. For the reasons provided, the request for right T7-T8 epidural selective nerve block injections with MAC has not been established as medically necessary for the 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 physical medicine and rehabilitation 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

A 56-year-old female enrollee has requested for computed tomography angiography (CTA) of the coronary arteries for evaluation of her chest pain. Findings:  Two physician reviewers found that the patient has little cardiac risk and presents with atypical chest discomfort.  Although there were very mild non-diagnostic ECG changes on the stress test, the more accurate nuclear perfusion images were reported as entirely normal.  Therefore, the test should not be considered equivocal or non-diagnostic, but rather negative.  In this circumstance, no additional cardiac testing for coronary ischemia is medically necessary at this time.
Appeal type: Experimental/Investigational
Decision: Overturned

A 63-year-old male requested authorization and coverage of carotid angioplasty and stenting. The Health Plan denied the request indicating that the requested procedure is considered experimental for treatment of the enrollees carotid artery stenosis.Three physician reviewers performed an experimental/investigational Independent Medical Review. Two physician reviewers concluded that the requested procedure is likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy. One physician reviewer concluded the requested procedure is not likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy. Because two of the three physician reviewers concluded that the requested procedure is likely to be more beneficial than any available standard therapy, the Health Plans denial has been overturned.
Appeal type: Experimental/Investigational
Decision: Upheld

A 26-year-old female enrollee requested Authorization and coverage of gastric bypass surgery with duodenal switch for the treatment of morbid obesity. The health plan denied the enrollees request indicating that the requested treatment is experimental.Three physician reviewers performed an experimental/investigational Independent Medical Review.  Two of the three physician reviewers concluded that gastric bypass surgery with duodenal switch is not likely to be more beneficial for treatment of the enrollees morbid obesity than any available standard therapy.  Because two of the three physician reviewers concluded that the requested treatment is not likely to be more beneficial for treatment of the enrollees medical condition than any available standard therapy, the review organization upheld the health plans denial.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:    The parent of an enrollee has requested gene testing (exome sequence analysis) for evaluation of the enrollees autism spectrum disorder and intellectual disability. Three physician reviewers found that the requested testing is likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The lack of a diagnosis can have considerable adverse effects for patients and their families, including failure to identify potential treatments, failure to recognize the risk of recurrence in subsequent pregnancies, and failure to provide anticipatory guidance and prognosis. A long-term search for a genetic diagnosis, referred to as the diagnostic odyssey, also has implications for societal medical expenditures, with unsuccessful attempts consuming limited resources. This patient is an appropriate candidate for the requested exome sequence analysis as it is likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: Three reviewers determined that the requested testing is 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: One reviewer is board certified in pediatrics with sub-specialty certification in clinical genetics and is actively practicing. One reviewer is board certified in pediatrics and genetics and is actively practicing.  One reviewer is board certified in pediatrics with sub-specialty certification in developmental-behavioral pediatrics and is 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.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for magnetic resonance imaging (MRI) of her knee. Findings:  The physician reviewer found that MRI of the knee has become the preferred method for imaging the knee to visualize pathology and assist in patient management and treatment. The knee is one of the most frequently injured joints, and knee pain can affect all age groups. Due to the diverse pathology, complex anatomy, and various possible injury mechanisms, the MRI knee protocol and sequences permit detection of both soft tissue and bony injuries in accurate detail. MRI is also sensitive for detecting early cartilage degeneration progressing to osteoarthritis, and can evaluate other joint structures which can be sources of pain following acute injury. Furthermore, the MRI scan can determine the type of meniscal tear, whether degenerative or traumatic, and can be useful in prescribing appropriate treatment. For these reasons, an MRI to evaluate this patients knee for a suspected lateral meniscal tear is essential to make a definitive diagnosis from the viewpoint of proper management. As such, the requested MRI scan of the knee is medically necessary for evaluation of this patients medical condition. Final Result: The reviewer determined that the requested services are medically necessary for evaluation 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 three-year-old female with a diagnosis of velocardiofacial syndrome with a history of global developmental delay with specific delays in gross motor skills. The patient has been receiving physical therapy for the gross motor delays since October 2004. In October 2005 the therapist documented gross motor delays at a 14-month level. In November 2005 the patient transitioned to another physical therapist and received seven therapy sessions from December 2005 to March 2006. At issue is whether continued physical therapy for the gross motor delays associated with velocardiofacial syndrome is medically necessary.   Review of the medical literature reveals no applicable scientific studies to support or refute the efficacy of physical therapy in patients with developmental delay.  However, physical therapy is commonly used to treat patients with developmental delay to address the goals as outlined in the clinical evaluation by the patients private therapist dated October 2005.  The goals as outlined are functional goals (walking up and down steps, single limb stance for dressing, and decreasing falls while running), which can be achieved in a reasonable amount of time. Since the family has stairs within the home this is not simply a school matter. The therapy, if successful, will significantly reduce the risk of falls.Chromosomal defects are a developmental condition.  However, there is no evidence that the patients condition precludes the efficacy of physical therapy. In this case the request for therapy is for specific treatment of motor strength and coordination to improve functional goals and is amenable to physical therapy. Physical therapy is warranted for the specific goals described. The therapy should be monitored every three months by a pediatric rehabilitation physician or developmental pediatrician experienced in prescribing therapies to ensure progress is being made.  If progress is not being made then a home program for the family should be established.For the reasons set forth above, I have determined the requested therapy is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Orthovisc injection series for right knee. Findings:  The physician reviewer found that An exhaustive review of the current medical literature pertaining to viscosupplementation reveals mixed results. Evidence from eight systematic reviews and six randomized controlled trials indicates that although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. Different studies have tried mixing hyaluronic acid with corticosteroids, platelet rich plasma, and other agents to make it more effective. 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 options are limited. The patient has tried and failed other treatments, including physical therapy, anti-inflammatory medications, and an intra-articular corticosteroid injection. Therefore, the requested Orthovisc injection series for the right knee is medically necessary for the treatment of the patients medical condition.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.