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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Avar LS.According to the most recent published guidelines of care from the American Academy of Dermatology, there is only limited evidence to support recommendations for sulfur and sodium sulfacetamide in the treatment of acne. There is a lack of support in the peer-reviewed literature demonstrating the efficacy of the requested medication in this clinical setting. Although there is some evidence to suggest the efficacy of sodium sulfacetamide, this is generally not peer-reviewed or well-supported. Additionally, Avar LS may be considered only a tertiary type of treatment. Medical literatures do not recommend sodium sulfacetamide or sulfur for the treatment of acne. In this case, the patient has been diagnosed with acne vulgaris. The medical evidence does not support the requested medication in this patients case. Therefore, the requested Avar LS is not medically necessary for the treatment of the patients medical condition.Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in dermatology 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

Nature of Statutory Criteria/Case Summary: The parent of the enrollee has requested authorization and coverage for sensory integration occupational therapy. Findings:  The physician reviewer found that there is significant controversy in the peer-reviewed literature regarding the effectiveness of sensory integration occupational therapy. The authors found that the methodology of the studies was poor. Most of the studies used weak designs, with a tendency for higher quality studies to produce negative results. Based on limited comparative evidence, functional analysis-based interventions for challenging behavior, such as applied behavioral analysis (ABA) therapy, were more effective than sensory integration therapy. Overall, the studies do not provide convincing evidence for the efficacy of sensory integration therapy. Given the lack of support in the peer-reviewed literature, the request for sensory integration occupational therapy has not been established as likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: Two of the three reviewers determined that the requested services are 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: One reviewer is board certified in pediatrics and neurology with special qualification in child neurology and is actively practicing. One Reviewer is board certified in pediatrics with sub-specialty certification in developmental-behavioral pediatrics 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: Upheld

A 63-year-old male enrollee has requested a follow-up visit with an otolaryngologist (ENT specialist) for the treatment of his obstructive sleep apnea. Findings:  The physician reviewer found that there is no mention in the submitted medical records that the patient is not tolerating CPAP or that there is a question of him having surgical treatment for his sleep apnea. As demonstrated by the literature, if the patient has questions about the CPAP device itself that his provider is not able to answer, a referral to a sleep medicine physician may be appropriate. Referral to an ENT specialist at this time is not appropriate unless there is a question of possible surgical intervention for this patient, which is not apparent from the records provided for review.
Appeal type: Medical Necessity
Decision: Overturned

A 64-year-old male enrollee has requested pulse dye laser treatment for treatment of his rosacea.  Findings:  The physician reviewer found that rosacea is a chronic inflammatory disorder characterized by periods of exacerbation, remission and possible progression. The major subtypes include erythematotelangiectatic rosacea and papular-pustular rosacea. Rosacea is as an inflammatory disorder with subtypes that are likely a result of different pathogenic factors and respond best to different therapeutic regimens. In rosacea, the pathogenesis is a polymorphic disease precipitated by many causes including genetic, vascular, immune-mediated, emotional, environmental, and infectious factors. The non-pharmacologic approach to therapy is adequate skin care, trigger avoidance and photoprotection. In addition, there are several topical, herbal, systemic and light based therapies available. FDA approved treatments include topical sodium sulfacetamide, metronidazole (Metrogel), and azelaic acid (Nally and Berson). Light based therapies with pulsed dye laser and intense pulsed light are effective in treatment of erythema and telangiectasias in patients with rosacea (Odom). Laser treatment can be used in combination with medical and topical treatments (Kennedy Carney, et al). The standard approach is to combine systemic anti-inflammatory effect of tetracycline antibiotics with topical anti-inflammatory and bactericidal treatments. Since this patient has failed standard treatments, a multifaceted approach to therapy that includes laser treatment is indicated. Therefore, the requested procedure is reconstructive in nature and medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for 2,000 punch hair graft. The Health Plan has denied this request indicating that the requested services are not medically necessary for treatment of the patients hair loss and are not reconstructive in nature. This patient has well-documented scar alopecia on the right side of the head, as a result of prior tissue transplant from the right temporal region of the scalp to relocate the tissue for penile reconstruction. This a complication of a medically necessary procedure. Therefore, reasonable intervention to correct this complication is medically necessary. However, the provider recommended a procedure for bilateral temple grafts (800 to 1,000 per side). A bilateral procedure is not consistent with the patients statement and previous documentation that specifically noted one-sided scarring/alopecia. Therefore, one side should be considered medically necessary, which includes 800 to 1,000 grafts. Specifically, hair graft to the right temple is medically necessary. Based on the records provided, the patients scar alopecia constitutes an abnormal presentation of the scalp. This abnormal condition is the result of the patients prior penile reconstruction for the treatment of Peyronies disease. The requested services are not likely to improve function, as there is no documentation of a functional impairment. However, the patient has an abnormal appearance of the right temporal scalp. Based on the photographs, a portion of the requested services is likely to provide more than a minimal improvement in appearance. In sum, a portion of the requested 2000 punch hair graft is reconstructive in nature. Specifically, hair graft to the right temple is reconstructive in nature. Final Result: The reviewer determined that the requested services is medically necessary and is reconstructive in nature for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned. Credentials/Qualifications: The reviewer 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 36-year-old female enrollee requested authorization and coverage of breast reduction surgery for the treatment of upper back pain.  The Health Plan denied the enrollees request indicating that the requested treatment is not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer overturned the health plans denial on the basis that the requested surgery is medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for LINX reflux management system.Findings:  Three physician reviewers found that there is a lack of randomized controlled trials with long-term follow-up demonstrating that LINX is safer or more effective than Nissen fundoplication or other surgical anti-reflux procedures. American College of Gastroenterology guidelines for the management of reflux disease state that more evidence is needed before LINX can be recommended. Additionally, LINX (more than surgical fundoplication) is associated with severe dysphagia requiring endoscopic intervention. Researchers concluded the long-term safety and efficacy of LINX, both alone and in comparison to current gastroesophageal reflux disease therapies, remains to be determined. The currently available peer-reviewed literature does not definitively support the conclusion that LINX is more likely to be beneficial in this case than standard treatment, surgical fundoplication. Thus, the requested LINX reflux management system is not likely to be more effective than other treatment modalities.Final Result: The reviewers determined that the requested services are 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: Upheld

A 65-year-old male enrollee has requested a wireless capsule endoscopy for evaluation of his possible lymphoma. Findings:  The physician reviewer found that the patient has mesenteric and retroperitoneal lymphadenopathy and the possibility of lymphoma (low grade). There is no evidence of occult gastrointestinal (GI) blood loss, and his hemoglobin and hematocrit are normal. As there are no signs of GI bleeding, wireless capsule endoscopy is not medically indicated for evaluation of the small bowel.
Appeal type: Medical Necessity
Decision: Upheld

A 63-year-old female enrollee has requested for sclerotherapy for treatment of her varicose veins. Findings:  The physician reviewer found that there is no evidence of a duplex scan or a recent trial of conservative treatment attempts.  Sclerotherapy cannot be recommended without evidence of failed conservative treatments and a duplex scan demonstrating the medical need for treatment.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 14-year-old male who weighs 490 pounds. The patient has comorbid conditions including obstructive sleep apnea, asthma, gastroesophageal reflux disease, and depression. It has been recommended that the patient undergo a Fobi pouch procedure. The Health Plan has denied authorization for bariatric surgery for the patient based on his age.Gastric bypass surgery is not medically indicated for this patient. The Fobi pouch procedure has upward of a 30% failure rate long-term. The risk of failure is even greater in the super morbidly obese (patients with a BMI greater than 50). Furthermore, the revision of Fobi pouch and gastric bypass is difficult and unsuccessful long-term in cases in which the vagus nerve has been transected. Given the patients age and BMI, the option of having the patient wait until the age of 17 to undergo gastric bypass surgery is medically reasonable and appropriate since there is no scientific data to demonstrate the long-term effects of bariatric surgery on children, particularly the impact of weight regain post gastric bypass.Based upon the information set forth above, I have determined that the requested procedure is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for qualitative or semiquantitative immunoassay testing (CPT 86352) provided by Moleculera Labs, Inc. The records provided for review document that this patient has undergone treatment with one medication trial, Sertraline, for management of his obsessive-compulsive disorder (OCD) and anxiety. Per the medical literature and The International College of Obsessive-Compulsive Spectrum Disorders, there is a lack of data to support a clinical role for the Cunningham Panel, as performed in this patients evaluation for treatment planning. In the medical literature, Hesselmark and Bejerot concluded that, clinical use of the Cunningham Panel in diagnosing PANS or PANDAS [pediatric acute-onset neuropsychiatric syndrome (PANS) and pediatric autoimmune neuropsychiatric disorder associated with streptococcal infection (PANDAS)] is not supported by this study. Moreover, this patients records do not document medication adjustment or change of behavioral approaches to support testing for medication management. All told, the qualitative or semiquantitative immunoassay testing (CPT 86352) provided by Moleculera Labs, Inc. was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Findings:  Three of the three physician reviewers found the qualitative or semiquantitative immunoassay testing (CPT 86352) provided by Moleculera Labs, Inc. was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The 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: Physician reviewers 1, 2, and 3 are board certified in psychiatry 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: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested inpatient detoxification services for treatment of the enrollees behavioral health conditions.  Findings:  The physician reviewer found that although inpatient detoxification services were indicated, the medical record does not demonstrate the necessity of the inpatient level of care for detoxification.   Despite the concerning report of delirium tremens and seizure, the patient had no prior clinical treatment for withdrawal. During the hospital stay, he was treated with a chlordiazepoxide taper. The records show that two days subsequent to the patients last use of medication for withdrawal symptoms, the patients vital signs were stable and his mental status examination was reassuring. The patient was not psychiatrically distressed. His laboratory studies were essentially normal. Aside from chronic shoulder pain, he had no medical complaints. Per the nursing notes, his gait was steady and he was not depressed. The patient was active in treatment; he led at a 12-step meeting on the unit. He was motivated and optimistic. His wife was supportive and he wanted to continue chemical dependency treatment. In sum, the record does not reflect that chemical dependency services provided in a less restrictive setting would have been inadequate. Therefore, the inpatient detoxification services were not medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the services at issue were 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 psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: A enrollee has requested reimbursement for all or any of the residential treatment center services provided. Findings:  The physician reviewer found that the submitted documentation does not support the medical necessity of the services at issue. The patient presented to the intensive outpatient program (IOP) with a history of substance use, which was mainly alcohol. The records noted that during treatment, the patient was cooperative, calm, and insightful into the patients psychological needs. The progress notes did not indicate that the patient had psychosis, paranoia or mania symptoms. The records did not indicate other severe psychiatric symptoms that would require intensive psychiatric care. The patient did not have self-harm behaviors and was medically stable. The medical record did not indicate the presence of any withdrawal symptoms. With regards to acute intoxication and/or withdrawal potential, the patient had a risk rating score of zero due to lack of withdrawal. In terms of biomedical condition and complications, the patient has a risk rating score of 0-1 due to no active serious medical problems. With regards to emotional/behavioral or cognitive conditions and complications, the patient has a risk rating score of 0-1 indicating some mild issues that were noted to be under good control with medications. In terms of readiness to change, the patient has a risk rating of 2 due to low motivation to change with some interest in continued treatment. With regards to relapse, continued use, or continued problem potential, the patient has a risk rating of 2 due to minimal sobriety. With regards to recovery/living environment, the patient has a risk rating of 1-2 due to no mentioned sober living environment. Overall, the patients presentation suggests risk-rating scores that range from 0 to 2. This overall risk rating is consistent with intensive outpatient services. In summary, all or any of the residential treatment center services provided were not medically necessary for treatment of this patient.Final Result: The reviewer determined that the services at issue were 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 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: Overturned

Nature of Statutory Criteria/Case Summary: The parent of the enrollee has requested authorization and coverage for at least six months of 150.5 hours per month of applied behavioral analysis (ABA) therapy for treatment of the enrollees autism spectrum disorder.Findings: The physician reviewer found that based on the documentation submitted for review, the patient has made progress as evidenced by the behavioral data submitted, but he continues to have problematic behaviors which jeopardize his safety. The patient also demonstrates delays in social skills and communication, lacking the ability to interact or demonstrate social/emotional reciprocity. He had a standard score of 73 on the Adaptive Behavior Composite (ABC), well below the normative mean of 100 which further underscores the patients delays in activities of daily living. The Behavior Analyst Certification Board states that typical comprehensive ABA programs range from 30 to 40 hours of treatment per week. In this clinical setting, the request for at least six months of 150.5 hours per month of ABA therapy is medically necessary for treatment of the patients autism. Final Result: The reviewers 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: Physician 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: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for  Erchonia XLR8 handheld cold laser device. As noted in the medical literature, one tool in the management of pain is low level laser therapy. The Erchonia XLR8 laser can provide temporary relief of chronic neck and shoulder pain, reduce pain after liposuction of the thighs, hips and stomach, or reduce post-surgery pain after breast augmentation. The U.S. Food and Drug Administration (FDA) has approved the Erchonia XLR8 laser in the setting of chronic pain in the neck and shoulder areas originating from osteoarthritis, muscle spasms, and cervical and thoracic spine strain. This patients records document a history of back pain, neck pain, and extraspinal subluxation in the left hip. The letter from the patients provider states that laser therapy was recommended for foot neuropathy, which is not an FDA-approved indication. There is a lack of evidence that the patient has any of the FDA-approved indications for treatment with the Erchonia XLR8 laser device. For these reasons, the Erchonia XLR8 handheld cold laser device was not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the device at issue was 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 neurology with subspecialty certification in vascular neurology 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.