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

A 56-year-old female enrollee has requested mental health services for treatment of her major depressive disorder, recurrent, severe. Findings:  The physician reviewer found that this patient denied any self-harm interest, and she showed no acute and agitated behaviors. The patients family members noted that the patient had a long history of alcohol and prescription drug abuse. Her treatment plan was focused on her trauma history and recovery. She participated in a program which included family week. The patient presented with an alcohol abuse problem, but was treated for traumatic stress. She presented with no acute or severe symptoms that required an inpatient level of care. Her symptoms, rather, were chronic and would not be expected to ameliorate with acute inpatient intervention.  All told, mental health services provided were not medically indicated.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement and prospective authorization and coverage for 137 hours per month of applied behavioral analysis (ABA) Findings:  The physician reviewer found that According to the documentation submitted for review, the patient continues to demonstrate significant problematic behaviors which include elopement, aggression, noncompliance and tantrums. The failure to address these behaviors puts the patient at an increased risk for injury, and makes it increasingly difficult to be successful in more generalized environments. The Behavior Analyst Certification Board indicate that typical comprehensive ABA programs range from 30 to 40 hours of treatment per week. Given the medical necessity of ABA for children with autism, the request for 137 hours per month of ABA therapy was and is medically necessary for treatment of the patients autism. Final Result: The reviewer determined that the services at issue were and are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in pediatrics with sub-specialty certification in developmental-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: Experimental/Investigational
Decision: Overturned

A 44-year-old male enrollee requested MiniMed 530G with Enlite (E0784 Insulin pump; A9277 continuous glucose monitoring (CGM) transmitter; A9276 x 3 CGM sensors) for medical treatment of his type 1 diabetes.  Findings:  Three physician reviewers found that the requested services are likely to be more effective for this patient than other available options. In this case, the patient is using an insulin pump and is still having low blood sugar levels in the 30-50s. He is checking blood sugars four times per day. Thus, the use of the new MiniMed 530G with Enlite system with the threshold suspend feature is likely to be beneficial for this patient and will likely lower the frequency of severe low blood sugars (Bergenstal, et al).
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for hypogastric nerve block injections with drugs to put the enrollee in a deep sleep (monitored anesthesia care (MAC)) services for treatment of the enrollees chronic abdominal pain secondary to Crohns disease and multiple abdominal surgeries. Findings:  The physician reviewer found that the patient has a diagnosis of chronic abdominal and pelvic pain secondary to Crohns disease status post multiple abdominal surgeries. The patient is currently maintained on Norco, Topamax and Baclofen and has failed conservative therapies. The patient previously underwent the hypogastric block with 40-50% improvement. Hypogastric blocks are an effective treatment for abdominal pain in this clinical setting. In this case, the patient has tried and failed multiple conservative measures and has noted significant improvement from prior hypogastric blocks. Furthermore, the hypogastric block is recommended to be performed on heavy conscious sedation or MAC to ensure proper needle position, patient safety, and comfort. Given these findings, the requested hypogastric nerve block injections with drugs to put the patient in a deep sleep (MAC) services are supported as medically necessary for treatment of this 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 anesthesiology with sub-specialty certification in pain medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 19-year-old female enrollee requested authorization and coverage of an ACL knee brace for treatment post surgery.  The health plan denied the enrollees request indicating that the requested knee brace is not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer upheld the health plans denial on the basis that the requested equipment is not medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Doppler-guided transanal hemorrhoidal dearterialization surgery.Three physician reviewers found that although it is a promising treatment for hemorrhoids, Doppler-guided transanal hemorrhoidal dearterialization is not supported by the current medical literature or guidelines as superior to other first-line alternatives. This treatment has success rates comparable to hemorrhoidectomy and stapled hemorrhoidopexy. The current studies have shown that Doppler-guided transanal hemorrhoidal dearterialization is comparable to conventional surgical hemorrhoidectomy for advanced hemorrhoidal disease in efficacy and safety. Further studies are needed to establish that Doppler-guided transanal hemorrhoidal dearterialization is more effective than established methods for the treatment of hemorrhoids. Therefore, Doppler-guided transanal hemorrhoidal dearterialization surgery was not likely to have been superior over other treatment options. Final Result: The 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: Physician reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in gastroenterology 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 fibroid removal surgery and corresponding full hospital stay. Uterine fibroids are typically benign tumors in the uterus that can cause heavy vaginal bleeding or bulk symptoms of pain and pressure. Uterine myomectomy is a procedure performed to remove fibroids while leaving the uterus intact. This treatment is effective for managing bulk symptoms associated with fibroid uteruses. Surgical intervention with hysterectomy or myomectomy are the only options for treatment of bulk symptoms. In this case, uterine myomectomy is consistent with the current standard of care for the removal of symptomatic fibroids. Given the size of this patients fibroid measuring 6 cm, the procedure will be performed via laparotomy. Typically, blood loss is minimal, and a patient can be discharged home after a period of observation. The records do not include documentation to support full admission following the fibroid removal surgery. Therefore, the requested fibroid removal surgery is medically necessary while a corresponding full hospital stay is not medically necessary for treatment of this patient. Final Result: The reviewer determined that a portion of the requested services is 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 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 56-year-old female enrollee has requested for total disc arthroplasty for treatment of her cervical degenerative disc disease.   Findings:  Three physician reviewers found that artificial disc replacement is based on the concept that by preserving motion, the progression of adjacent-segment degeneration will be lessened (see Baaj and colleagues). However, the effectiveness of these implants is still uncertain, and may be related to the progression of the natural history of arthritic disc (Denaro and colleagues). Early results of the procedure have been encouraging, but the importance of long-term studies to demonstrate maintenance of these results has been stressed (Murrey and colleagues), and was included in the original approval of the ProDisc-C. In addition, heterotopic ossification has been seen in many patients (Mehren and colleagues), and the clinical significance of this may be variable and requires study (Suchomel and colleagues). Further, artificial disc replacement surgery adjacent to levels that have prior fusion potentially leads to a greater risk of failure because of the increased biomechanical forces. Continued studies are needed to clarify this (Phillips and colleagues).
Appeal type: Medical Necessity
Decision: Overturned

The parent of a two-year-old male enrollee has requested individual speech and language therapy in English and Vietnamese for a total of two hours per week for treatment of the enrollees language delay.  Findings:  The physician reviewer found that this patient had essentially not developed any speech when his expressive language was noted to be at 6 months when tested both in English and Vietnamese at the age of 2-years-5-months old.  Law, et al. reported that children with speech delay can be effectively treated with speech therapy. Children with speech delays, including those with cognitive delays, are candidates for successful speech therapy (Goorhuis-Brouwer & Kniff). Two-year olds who tested below the 10th percentile, such as this patient, do require and benefit from speech therapy (Emanuel, et al. and Buschman, et al.). Speech therapy is medically indicated for this patient. The medical community standard for a two-year-old non-speaking child is speech therapy.
Appeal type: Medical Necessity
Decision: Upheld

A 44-year-old female enrollee, who underwent a nondivided Roux-en-Y gastric bypass, has requested authorization for gastric bypass revision.Findings:  The physician reviewer found that clinical evidence suggests this is a case of noncompliance with the patients post-surgical dietary regimen. The fact that the patient never lost more than 30 pounds, even early on when the pouch had not yet stretched, suggests maladaptive eating behaviors. Evidence suggests no anatomic reason for the patients regain and many clinicians leave pouches larger than 30ml with good results.
Appeal type: Medical Necessity
Decision: Upheld

A 33-year-old female enrollee requested authorization and coverage of a PET scan of the brain followed by a whole body PET scan for the treatment of toxic leukoencephalopathy.  The health plan denied the enrollees request, indicating that the requested PET scans are not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer upheld the health plans denial on the basis that the requested PET scans are not medically necessary.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for vacuum assisted wound therapy for treatment of the enrollees foot ulcers. Findings:  2/3 of the physician reviewers found that negative wound pressure treatment (NWPT) is appropriate for this patients diabetic foot infection. There have been multiple peer reviewed studies supporting the effectiveness of NWPT for treatment of diabetic foot ulcers. A study by colleagues concluded, With emergent evacuation of abscess, early vascular intervention and appropriate debridement, NPWT can be a useful adjunct to the management of limb-threatening diabetic foot infections.  Another study by colleagues noted, NPWT appears to be as safe as and more efficacious than advanced moist wound therapy for the treatment of diabetic foot ulcers. As such, there has been consistent evidence of the superior benefits of this modality when compared to conventional treatments for foot ulcers. All told, the vacuum assisted wound therapy was likely to have been more efficacious than other methods for treating this patients medical condition. Final Result: 2/3 of the reviewers determined that the services at issue were likely to be 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 reviewer number one is board certified in plastic 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.Physician reviewer number two is board certified in plastic 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.Physician reviewer number three is board certified in plastic 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

A 62-year-old male enrollee requested authorization and coverage of gastric bypass surgery. The Health Plan denied the request indicating that the requested surgery is not medically necessary for treatment of enrollees morbid obesity.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plans denial on the basis that the requested procedure is medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

The representative of a 42-year-old female enrollee has requested continued acute inpatient rehabilitation services for the enrollees rehabilitation following a stroke. Findings:  The physician reviewer found that the submitted clinical evidence demonstrates that the technology used as part of the patients rehabilitation as well as expertise in its use have been an essential component of her progress. The technology used in this case is not usual and customary in subacute rehabilitation. The acute inpatient rehabilitation services the patient has been receiving are a vital part of her rehabilitation and should be continued.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for lumbar spinal fusion multilevel, which includes surgery for a single level fusion at L3-L4 and a cervical surgery to remove hardware and instrumentation from the patients neck. The Health Plan has denied this request indicating that the requested services are not medically necessary for treatment of the patients degeneration of lumbar intervertebral disc disease and cervicaglia. The submitted documentation supports the medical necessity of the requested services. There is substantial medical literature with regard to the performance of fusion procedures for degenerative disease of the lumbar spine with or without the presence of instability. In this patients case, the providers assessment noted there is adjacent segment disease at L3-4, retained instrumentation cervical spine posteriorly, and   bone scan confirmation of worsening endplate reactive change consistent with axial instability at that level. The fusion at L4-5 is solid. Based on the current guidelines, in the presence of adjacent segment disease and instability at L3-4, the requested anterior and posterior fusion procedure at L3-4 is likely to be beneficial for the patients degenerative disc disease. The patient has a bulging disc at L3-4. The bone scan demonstrated evidence of instability, which has not responded to nonoperative treatment. With regard to the request for cervical implant removal for continuing pain, the literature indicates a substantial improvement in pain levels in the majority of patients undergoing similar procedures. The medical records document the presence of a solid fusion. As such, removal of hardware from the cervical spine is supported. Therefore, lumbar spinal fusion multilevel, which includes surgery for a single level fusion at L3-L4 and a cervical surgery to remove hardware and instrumentation from the patients neck, is reasonable, appropriate, and 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: Upheld

An enrollee has requested authorization and coverage for Roxicodone 30 mg (146 pills every 30 days), and fentanyl (10 patches every 30 days).The patient had cervical spine surgery and he is still complaining of neck and right hand pain. He is currently on high dose opioid therapy, and he is requesting to be re-started on fentanyl patches which were stopped two years ago. The patient is also requesting the brand name medication Roxicodone because he feels that the generic version of this medication (oxycodone) is not as effective. Records indicate that alternative treatments have been offered and were declined, or the patient has not expressed interest at this time. With regards to the differences between the brand name and generic medications, the FDA mandates that generics perform exactly the same way as a brand name drug would. The active ingredient in this case, oxycodone, is the same in both name brand and generic formulations, and the patient has used the generic version in recent months with no adverse effects. With regards to the patients request to restart the fentanyl patch, the patient has been off the patches for two years, and he is already on high doses of opiates (225 mg morphine equivalents). Resuming the use of fentanyl patches at this time would put the patient at very high risk for overdose and death, since he is also using diazepam. CDC guidelines do not recommend that patients be on both opiates and benzodiazepine medications at the same time, and the provider has developed a treatment plan that is consistent with the most recent national guidelines regarding opioid therapy that include non-pharmacological treatments. Under these circumstances, the requested Roxicodone 30 mg (146 pills every 30 days), and fentanyl (10 patches every 30 days) are not medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested medications are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in anesthesiology, with subspecialty certification in pain medicine, and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 62-year-old male enrollee requested authorization and coverage of Vioxx. The Health Plan denied the request indicating that the requested medication is not medically necessary for treatment of the enrollees bilateral degenerative joint disease of the knee.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plans denial on the basis that the requested medication is medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

A 55-year-old female enrollee has requested right peroneal nerve surgery for treatment of her peroneal nerve entrapment.  Findings:  The physician reviewer found that at issue is the medical necessity of surgery to release entrapment of the right peroneal nerve. There is limited relevant literature regarding peroneal nerve entrapment surgery. In a study by Fabre, et al. it was described that in the 60 patients who had entrapment of the peroneal nerve, electrophysiological studies were performed for all patients in order to confirm the diagnosis. The results were generally favorable and the authors recommended operative decompression when symptoms persist or recovery remains incomplete for three to four months, provided that the diagnosis has been confirmed with electrophysiological studies. In the case of this patient, there is no evidence of electrophysiological or imaging studies to objectively demonstrate entrapment of the right peroneal nerve. Further, based on the results of the patients previous left peroneal nerve procedure, surgery on her right peroneal nerve is unlikely to provide any significant benefit.  All told, the clinical evidence provided does not support the medical necessity of right peroneal nerve surgery.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 14-year-old female enrollee has requested removal of moles from the chest for treatment of the enrollees skin lesions.  Findings:  The physician reviewer found that given the possibility that an atypical melanocytic nevus can harbor premalignant or malignant cells, excisional biopsy of the lesion is warranted. Careful analysis of histologic features as well as the additional information provided by immunohistochemistry is needed for a correct diagnosis in most cases of melanoma in children. The lesion should be entirely excised to assure that no abnormal cells are left in the skin. Further, the expertise of a plastic surgeon is indicated to prevent scarring on the patients chest. This diagnostic, rather than cosmetic procedure is therefore medically necessary for treatment of this patients medical condition.