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

A 43-year-old female enrollee has requested transcranial magnetic stimulation (TMS) for treatment of her major depressive disorder. Findings:  Two physician reviewers found that TMS is not likely to be more beneficial to this patient, based on the current literature and this patients clinical scenario. The most recent note provided from the patients treating psychiatrist indicates that her depressive symptoms improved on a therapeutic trial of an antidepressant. Additionally, she has a comorbid diagnosis of generalized anxiety disorder and there is no evidence to support the use of TMS for this disorder or in depression where this condition is comorbid. The study by Eranti, et al. indicates that electroconvulsive therapy (ECT) is more effective in this setting and the American Psychiatric Associations practice guidelines indicate ECT is the most effective treatment for depression. ECT also has evidence based efficacy in reduction of suicidality. Additionally, the Cochrane review indicates that there is insufficient evidence supporting the efficacy of TMS to warrant its use in standard practice and the current research does not establish its superiority over antidepressant medications, especially in treatment-resistant patients. In sum, the data reviewed fail to demonstrate that TMS is likely to be more beneficial than any treatment alternative and TMS does not appear to be warranted clinically, given the patients response to an antidepressant.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a motor scooter to perform one or more mobility-related activities of daily living (ADLs) or instrumental ADLs in or out of the home, including access to the community. Hagan and colleagues note that exercise therapy has beneficial clinical effects for most musculoskeletal conditions. In this case, the patient reported multiple health conditions, including pain, neuropathy, and arthritis, that may be helped through gradually increased levels of light physical activity and exercise, such as the use of a manual wheelchair. Given that the records reflect that the patient is able to ambulate with a walker and has the capacity to propel a manual wheelchair, the requested equipment is not medically indicated. Therefore, a motor scooter is not medically necessary for this patient to perform one or more mobility-related ADLs or instrumental ADLs in or out of the home, including access to the community.Final Result: The reviewer determined that the requested equipment 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 physical medicine and rehabilitation and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Pathfinder TG testing provided for evaluation of the enrollees possible pancreatic cancer. Findings:  Three reviewers found that the molecular markers are often performed on pancreatic cyst fluid given the difficulty in determining the risk of malignancy. A biomarker panel consisting of the immunoassays TIMP1 and LRG1, along with CA 19-9 improved the detection of early-stage pancreatic cancer, relative to CA 19-9 alone, and is supported by the National Comprehensive Cancer Network (NCCN) guidelines. Final Result: Two of three physician reviewers determined that the testing at issue was 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: All three physician reviewers are board certified in internal medicine with sub-specialty certification in medical oncology 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 reimbursement for the preconceptional genetic testing (CPT codes 81200, 81209, 81242, 81251, 81255, 81256, 81257, 81260, 81290, 81330, and 81400). As noted by the American College of Obstetricians and Gynecologists (ACOG), some screening tests are routine and offered to all pregnant women, while others are generally only ordered when a genetic trait is suspected. According to the ACOG practice bulletins, screening for spinal muscular atrophy (SMA) and cystic fibrosis should be offered to all women who are considering pregnancy or are currently pregnant. In addition, fragile X carrier screening is recommended for women who are considering pregnancy or are currently pregnant and have a family history of fragile X related disorders or intellectual disability suggestive of fragile X syndrome. Screening for Tay-Sachs disease should be offered when considering pregnancy or during pregnancy if either member of a couple is of Ashkenazi Jewish, French-Canadian, or Cajun descent. In this instance, this patients records do not document any of these indications for specific testing. The standard of care includes testing for SMA and cystic fibrosis, not the entire Preparent Global Panel. Thus, preconceptional genetic testing (CPT codes 81200, 81209, 81242, 81251, 81255, 81256, 81257, 81260, 81290, 81330, and 81400) was not likely to be more beneficial for evaluation of this patients medical condition than any available standard testing. One reviewer found that preconceptional genetic testing (CPT codes 81200, 81209, 81242, 81251, 81255, 81256, 81257, 81260, 81290, 81330, and 81400) was likely to be more beneficial for evaluation of this patients medical condition than any available standard testing.Final Result: Two of the three reviewers determined that the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications:  One reviewer is board certified in obstetrics and gynecology and is actively practicing. One Reviewer is board certified in obstetrics and gynecology and is actively practicing.  One Reviewer is board certified in obstetrics and gynecology 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: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for lumbar surgery. Findings:  The physician reviewer found that the documentation provided for review does not support the medical necessity of the requested services. Numerous studies have demonstrated the role of surgical decompression in this patient population; however, few have investigated the utility of fusion in patients without underlying instability. The inclusion of fusion is recommended for patients with demonstrated spinal instability or the likelihood of iatrogenic instability. This patient presents with severe back pain radiating into the right lower extremity in an S1 distribution. Functional limitations are noted in activities of daily living. She is unable to walk without crutches. Clinical findings document motor deficits, reflex changes, and sensory deficits consistent with imaging evidence of L5-S1 disc protrusion with right S1 nerve impingement. There is also imaging evidence of minimal degenerative disc changes at L3-4, L4-5 and L5-S1. She has failed long term reasonable and/or comprehensive non-operative treatment, including physical therapy, epidural steroid injections, activity modification, and medication. There is no radiographic evidence of spondylolisthesis or spinal segmental instability on flexion and extension x-rays. There are plausible apparent discrepancies between the radiologist and the providers description of normal versus flat back alignment of the lumbar spine. In addition, the prior deferred surgically proposed procedures were considered for L3-S1 and most recently have been considered for L2-S1. At the present time, the rationale for these discrepancies have not been provided and/or is not apparent. Therefore, the requested lumbar surgery is not 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 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

The patient is a 34-year-old female who is seeking authorization for repair of her abdominal wall changes secondary to three pregnancies. Her obstetrician referred her to a board certified plastic surgeon who noted the problem and recommended repositioning of the rectus fascia and abdominoplasty (usually considered one procedure as there is no true hernia). The Health Plan has denied authorization for the requested procedure on the basis that it is considered cosmetic in nature.A review of the presented records, including photocopies of photographs, demonstrates an intact pair of rectus abdominis muscles with some spread in midline (diastasis) and excess skin and soft tissue of the abdominal wall. The information presented does not demonstrate the patient has any functional deficits related to her present condition. Furthermore, there is no evidence the proposed surgery would correct a functional deficit. Therefore, I have determined the requested procedure is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

The enrollee is requesting authorization and coverage for Orthovisc injections to the right knee. The enrollee has a medical history of osteoarthritis and chronic pain in his right knee. The enrollee has tried non-steroidal anti-inflammatories, physical therapy, and platelet-rich plasma injection with little relief. He has been receiving Orthovisc injections, which have provided significant pain relief. The enrollees treating physician reports the enrollee is not a surgical candidate for knee replacement, nor are there any other surgeries that can be offered which would provide any benefit. Literature shows intra-articular injections of hyaluronic acid, among other medications, are being used as an alternative therapy in osteoarthritis in order to maximize the topical effect and minimize adverse effects. Hyaluronic acid injections appear to be the safest and longest-lasting of the injectable alternatives. Researchers report on a systematic review which shows hyaluronic acid injections for knee osteoarthritis provide a small, but significant, benefit with respect to function. Because this enrollee is not a candidate for total knee replacement surgery, and he has responded positively to hyaluronic acid in the past, it is reasonable that a repeat set of hyaluronic acid injections would be appropriate for this enrollee.Final Result: The reviewer determined that the requested service is medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement and prospective authorization and coverage for 30 hours per week of direct applied behavioral analysis (ABA) therapy for treatment of the autism spectrum disorder.  Findings:  The physician reviewer found that the documentation submitted for review does not support the medical necessity for 30 hours per week of direct ABA therapy. The 20 hours per week of ABA therapy authorized by the Health Plan is medically reasonable for this patient. According to the documentation submitted for review, the patient is making progress with ABA therapy, and there does not appear to be a medical indication for 20 hours per week of direct ABA per week. The patient is documented have had stable or improved performance across all areas. The patient is becoming increasingly more open and responsive to his treatment, and he is learning to take more responsibility for the patients actions and behaviors. Based on the clinical documentation submitted for review the services at issue were not and are not medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the services at issue 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 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: Medical Necessity
Decision: Overturned

The parents of a 16-year-old female enrollee have requested authorization and coverage for continued residential treatment for treatment of the enrollees major depression, severe, recurrent; bipolar disorder; eating disorder; borderline personality disorder; polysubstance abuse; and deterioration in level of functioning.  The health plan has denied this request indicating that continued residential treatment is 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 the requested services are medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: A 56-year-old female enrollee has requested authorization and coverage for sclerotherapy (six treatments). Findings: The physician reviewer found that the request for sclerotherapy (six treatments) is not medically necessary for treatment of the patients medical condition. The treatment for varicose veins is to identify the patient, and offer conservative therapy. If the patient is successful with conservative therapy, no further intervention is required. However, if the patient fails conservative therapy, then ablation and removal of the axial veins and interruption of significant non axial accessory varicosities is indicated. Traditionally high ligation of greater saphenous vein (GSV) with stripping and stab avulsions are recommended with probable maximum symptomatic relief of up to 10 years. Currently, endovenous ablation of greater saphenous vein in combination with stab avulsions is the standard of care. There is ample medical literature suggesting that both laser and radiofrequency ablation of the GSV is superior to high ligation and GSV stripping. It produces the same clinical efficacy, has a shorter recovery time, greater patient acceptance. Significantly higher failure and complication rates were seen in short saphenous vein and anterior saphenous vein treatment as compared with GSV treatment. The medical literature suggests that the current place of sclerotherapy in modern clinical practice is limited to the treatment of accessory recurrent varicose veins following surgery and thread veins. All told, the requested service is not medically necessary for treatment 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 surgery and 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: Overturned

The spouse of a 59-year-old female enrollee has requested inpatient skilled nursing care for the treatment of the enrollees medical condition. Findings:  The physician reviewer found that the nationally accepted guidelines for inpatient skilled services provide that a patient must require daily skilled rehabilitation and be receiving such services. Review of the submitted clinical evidence demonstrates that this patient met the guidelines for skilled care. She required and was receiving daily skilled rehabilitation. She had shown steady improvement with the therapy and further progress was expected with continued daily skilled services. Based upon the patients clinical presentation and functional status, it was medically appropriate to continue skilled services.
Appeal type: Medical Necessity
Decision: Upheld

A 40-year-old female enrollee has requested authorization and coverage for surgery to unblock the right fallopian tube.   Findings:  The physician reviewer found that hysterosalpingogram (HSG) is the initial diagnostic test used to assess tubal patency because it has a sensitivity of 85% to 100% in identifying tubal occlusion (Yao and Schust). If external assessment of the fallopian tubes is warranted, laparoscopy is the best technique for diagnosing abnormalities.  It is possible that the sonohysterogram was the initial diagnostic test as opposed to the HSG, which was recommended because endometrial cells were noted on the patients Pap smear.  If the practitioner wanted to sample the endometrial lining at the time of sonohysterogram based on abnormal findings in the endometrial canal, it would have been an appropriate course of action (Moschos, et al.).Given the above information and lack of documented abnormal symptoms as it relates to the patients menstrual cycles the requested procedure is not medically necessary, unless a diagnosis of a blocked fallopian tube is confirmed via HSG. Additionally, there is not a complete fertility work-up documented to warrant surgery at this time. Therefore, the requested procedure is not medically necessary at this time.
Appeal type: Medical Necessity
Decision: Upheld

A 24-year-old female enrollee has requested a gastric sleeve surgery without the pre-operative weight loss requirement for treatment of her obesity.  Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the requested gastric sleeve surgery without the pre-operative weight loss requirement. The patient does not meet the National Institutes of Health (NIH) criteria for weight loss surgery. Bariatric surgery is indicated for patients with a BMI of 40, or a BMI of at least 35 with severe co-morbid conditions. This patient has a BMI of 42.45, however this patient has not completed a multidisciplinary evaluation. Moreover, there is no dietary evaluation, no documented medical clearance and there is no documentation of failed weight loss efforts. All told, the medical necessity of the requested procedure has not been established.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested breast tomosynthesis for evaluation of her medical condition.  Findings:  Three physician reviewers found that the current medical evidence supports the services at issue in this clinical setting.  The addition of breast tomosynthesis to screening mammography has gained worldwide popularity among radiologists due to an associated decrease in callbacks and increase in detection of small cancers.  The advantage is the ability to sort out dense glandular tissue from underlying architectural distortion and mass due to the tomographic qualities of the new technique.  Breast tomosynthesis is beneficial for evaluating women with very dense or heterogeneously dense breast tissue.  Thus, breast tomosynthesis performed was likely to have been of greater benefit to the patient than digital two-dimensional mammography alone.Final Result: Three reviewers determined that the services at issue were 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: The three reviewers are board certified in diagnostic radiology and is actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 16-year-old male enrollee has requested Gamma Knife stereotactic radiosurgery (STR) for treatment of the enrollees Cushings disease.  Findings:  The physician reviewer found that Gamma Knife STR for treatment of residual tumor was clinically appropriate in this case and consistent with the standard of care. Gamma Knife is very precise treatment for tumors such as this that are close to optic apparatus. The immobilization during Gamma Knife treatment is rigid and more precise. Furthermore, Gamma Knife is a one-day procedure compared to other STR options. Gamma Knife was the most beneficial option for treatment of the patients recurrent disease, and was medically reasonable and appropriate.
Appeal type: Medical Necessity
Decision: Upheld

A 22-year-old female enrollee has requested for partial hospitalization program level of care services for treatment of her anorexia nervosa.  Findings:  The physician reviewer found that this patient indicate her motivation, self-care skills and recognition of the need for treatment are sufficient for the patient to reduce her eating disorder behaviors and gain weight with outpatient treatment. Applying the American Psychiatric Association (APA) practice guidelines, this patient was a candidate for treatment in a lesser restrictive environment such as intensive outpatient program (IOP).