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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for magnetic resonance imaging of the shoulders. A study indicates that shoulder pain is the third most common musculoskeletal complaint in orthopedic practice. Shoulder pain is usually due to a defect of the rotator cuff and/or an impingement syndrome. Shoulder pain is a very common symptom. Disorders of the rotator cuff tendons due to wear or tear are among the most common causes of shoulder pain and disability. A SLAP (superior labral tear from anterior to posterior) lesion may also be present. Magnetic resonance imaging, magnetic resonance arthrography, and ultrasound are increasingly being used to assess the presence and size of rotator cuff tears to assist in planning surgical treatment. It is not known whether one imaging method is superior to any of the others. In this case there is a chronic history of shoulder pain. The patient depends upon their upper extremities as there is a history of paraplegia. The enrollees pain is not relieved by conservative treatment. As such, the need for imaging studies to determine proper treatment is clearly evident. In light of the foregoing, the request for magnetic resonance imaging of the shoulders is reasonable, appropriate, and medically necessary.Final Result: The reviewer determined that magnetic resonance imaging of the shoulders is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for acute inpatient mental health treatment for treatment of the enrollees behavioral health conditions.  Findings:  The physician reviewer found that The physician reviewer found that the submitted documentation demonstrates the medical necessity of the services at issue. Modern psychiatric practice aims to place patients in the least restrictive treatment setting. In general, community-based settings are preferred as they offer optimization of treatment gains. However, placement in more restrictive settings is often clinically appropriate. In this patients case, he had not yet consolidated the illness burden that prompted the admission. The inpatient setting remained recommended by the attending provider due to the patients inability to effectively provide self-care. He was isolative, depressed, guarded and irritable. He was becoming less communicative, taking long periods of time to respond, if at all. In addition to the thought blocking, there were growing concerns of preoccupying internal stimuli. The patient refused to eat, even though he was hungry. Despite prompting from staff, he was not engaging treatment on the unit. Since he was reportedly stealing, was unpredictable, and was refusing aftercare planning, discharge to family was not an option at the time. The records support a protracted acute psychiatric syndrome. Discharging a patient under such circumstances would have been inconsistent with current practice standards. However, as the admission progressed, the patient began to slowly embrace therapeutic offerings. He was started first on an antidepressant followed thereafter by a second-generation antipsychotic. He eventually began attending groups and participating in discharge planning, which ultimately facilitated transition to the outpatient setting. During the disputed timeframe, the acute inpatient setting remained safe, appropriate, and consistent with good medical practice. The services at issue were reasonably expected to both improve the patients condition and prevent a more serious episode of illness while assisting with diagnostic formulation. Further, the duration of services was consistent with community standards for a case of this severity. All told, acute inpatient mental health treatment was 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: Experimental/Investigational
Decision: Overturned

A 44-year-old male enrollee has requested for Comprehensive Colaris and Concurrent PMS 2 Sequencing Test for evaluation of his family history of colorectal cancer. Findings:  Two physician reviewers found that Lynch syndrome is a genetic susceptibility to the development of a variety of different cancer types that occurs in certain families.  Lynch syndrome is detected by the requested testing.  The current medical guidelines support the requested testing for individuals without personal cancer if they have two or more first-degree or second-degree relatives with a Lynch related cancer, such as colon cancer. In this clinical setting, the requested Comprehensive Colaris and Concurrent PMS 2 Sequencing Test is likely to be of greater benefit than other available methods of evaluating this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

A 24-year-old female enrollee has requested for surgical excision of the axillary sweat glands for treatment of her hyperhidrosis. Findings:  Two physician reviewers found that excision of axillary sweat glands is an invasive/destructive procedure. There exist other non-invasive treatments that the patient has not yet tried such as Botox or iontophoresis.  Should these methods be ineffective or contraindicated, axillary excision would be reasonable given the widespread effects of sympathectomy. However, a trial of non-invasive therapy is reasonable before undertaking surgery.
Appeal type: Medical Necessity
Decision: Upheld

A 61-year-old female enrollee has requested coverage for past anesthesia services provided during a colonoscopy.   Findings:  The physician reviewer found that the patient underwent a routine screening colonoscopy. She has no significant comorbidities. In cases such as this, the standard of care remains to sedate the patient with a combination of an IV benzodiazepine and an IV narcotic which are safe and effective. Given the patient was healthy and had no other contraindications to benzodiazepines or narcotic medications, there was no indication for propofol. In sum, the anesthesia services provided on were not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

A 54-year-old female enrollee has requested an anesthesiologist for monitored anesthesia care (MAC) for treatment of her medical condition.  Findings:  The physician reviewer found that the service of an anesthesiologist for monitored anesthesia care (MAC) was not medically necessary for the patients colonoscopy and upper endoscopy. The patient did not present with a medical history that would require monitored anesthesia care. The standard of care for monitored anesthesia care for a minimally invasive procedure is airway difficulty, large fluid shifts and co-morbid conditions that would put the patient at risk during the procedure. There is no evidence within the documentation submitted for review of co-morbid conditions that would place the patient at risk for complications requiring the need for monitored anesthesia care. Moreover, a colonoscopy may be safely and effectively performed with conscious sedation of a benzodiazepine alone or with a narcotic in an office-based setting and without the need of monitored anesthesia care with propofol, as required per the American Society of Anesthesiologists (ASA) guidelines. Based on the documentation submitted for review and the peer-reviewed literature cited above, the services at issue were not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for a right total hip arthroplasty. The Health Plan has denied the request as not medically necessary. Total hip arthroplasty is a very successful and effective orthopedic operation with very good immediate as well as long-term results to alleviate pain and improve the quality of life of the patient. It is indicated in end-stage hip osteoarthritis in patients with a clear indication, as in this case. The decision for total hip arthroplasty includes evaluation of the medical history, clinical examination, and radiographic findings, and the degree of suffering; in addition to, having clear outcome expectations. The timing of the total hip arthroplasty is based on the patient's level of discomfort, the main goal being, to improve the quality of life.In this case, the records document subjective, objective, and radiographic findings consistent with end stage osteoarthritis. The literature supports that after four years of symptoms and with this degree of disease, it is unlikely for conservative treatment to provide long term relief. As such, the right total hip arthroplasty is medically necessary for the treatment of the patients medical condition.Final Result: The reviewer determined that the requested surgery is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in 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

A 53-year-old female enrollee has requested continued Myobloc injections for the treatment of her cervical pain. Findings:  The physician reviewer found that there is inadequate documentation of the durational characterization of the patients cervical dystonia to support the need for Myobloc injections. Specifically, the degree of rotation, flexion and extension are not delineated. Additionally, there is no indication whether the dystonia occurs with specific actions, is characterized by overflow, or is present at rest. Nor is it documented whether certain sensory tricks temporarily suppress dystonia movements. Furthermore, the duration of the cervical dystonia is not clearly delineated in the records provided. As such, there are insufficient findings supporting the need for further treatment with Myobloc.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a seven-month-old male who during his two-month well-baby exam was noted to have mild torticollis and some flattening of the right occiput.  Conservative treatment was discussed.  At three-months of age, the baby had increased flatness at the back of his head, primarily on the right, and an anterior shift of the right ear.  He was diagnosed with positional plagiocephaly and a cranial orthotic was advised.  The baby was fitted for the device and his parents are now requesting reimbursement for the cost.  The Health Plan has denied their request based upon a determination that the orthotic device was not medically necessary.Treatment of positional plagiocephaly with the helmet device is controversial.  With babies now sleeping exclusively on their backs, we are seeing positional plagiocephaly commonly.  Conservative practical treatment is effective in almost all cases, as it predictably will be for this child as well.  We are reserving helmet treatment to those infants with severe problems, defined as one ear one or more centimeters more anteriorly positioned than the other ear.  Since this child was making progress without the helmet, as indicated in January 2005 during casting for the helmet, there is no evidence demonstrating the need for its use.  Based upon the information set forth above, I have determined the device at issue was not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

The representative of a female enrollee requested authorization and coverage of lumbar percutaneous disc decompression. The Health Plan denied the request indicating that the requested procedure is considered experimental for treatment of the enrollees back pain.Three physician reviewers performed an experimental/investigational Independent Medical Review. Two of the physician reviewers concluded that the requested procedure is not likely to be more beneficial for treatment of the enrollees medical condition than any available standard therapy at this time. One of the physician reviewers concluded that the requested procedure is likely to be more beneficial for treatment of the enrollees medical condition than any available standard therapy. Because two of the three physician reviewers concluded that the requested therapy is not likely to be more beneficial for treatment of the enrollees medical condition than any available standard therapy at this time, the Health Plans denial has been upheld.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Mohs surgery for treatment of the enrollees skin cancer. Findings: The physician reviewer found that there is sufficient support for the requested procedure in this clinical setting. The patient had a biopsy-proven basal cell carcinoma involving the forehead. Mohs micrographic surgery is a technique whereby the best chance of tumor clearance is obtained while minimizing removal of normal tissue.  The Mohs appropriate use criteria is a nationally recognized algorithm, which provides recommendations for the use of Mohs surgery depending on tumor, size and location. In this patients case, the finding of a biopsy-proven basal cell carcinoma on the forehead meets the Mohs appropriate use criteria. Final Result: The reviewer determined that the requested procedure is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in 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: Medical Necessity
Decision: Upheld

The patient is a 55-year-old male who is status post gastric bypass in February 2004 followed by massive weight loss of approximately 150 pounds. He is now seeking authorization for panniculectomy, which has been denied by the Health Plan.The information submitted does not demonstrate the patient meets accepted criteria for authorization of a panniculectomy. Although the patient has undergone massive weight loss there is no evidence he has experienced chronic skin infections that have not been amenable to conservative treatment. In addition, there is a lack of evidence demonstrating significant functional impairment. 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: Upheld

The parent of a 17-year-old male enrollee has requested residential treatment services for treatment of the enrollees polysubstance abuse and depression. Findings:  The physician reviewer found that the patient did not meet the ASAM criteria for admission to a residential treatment center. The patient had no biomedical conditions and there was no need to protect the patient or provide a 24-hour structured environment. The patient had adequate social functioning and was able to manage his activities of daily living. The patient could have participated at a lesser level of care.
Appeal type: Medical Necessity
Decision: Overturned

A 53-year-old female enrollee has requested an adjustable oral appliance (SomnoMed) for the treatment of her obstructive sleep apnea (OSA). Findings:  The physician reviewer found that sleep apnea, if left untreated, can lead to serious cardiac and gastrointestinal disorders. This  patient cannot tolerate CPAP, but had moderate success with a fixed, non-adjustable appliance. Assuming that the symptoms only occurred in the right TMJ as reported, it is consistent with therapeutic guidelines to assume that a different oral appliance could work. Certainly, with any orthotic trials of different types may be needed to find the one that is most effective. The same is true for oral appliances. The SomnoMed device is totally different than the TAP-2 appliance and a trial of the device is reasonable. There are limited treatment alternatives at this juncture, and severe sleep apnea should not go untreated.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for the gammaCore vagus nerve stimulator. In the peer-reviewed medical literature, Straube and colleagues noted that treatment of chronic migraine by vagal nerve stimulator at 1 Hz was safe and effective. In this randomized monocentric clinical trial, the authors found that the mean reduction of headache days after 12 weeks of treatment exceeded that reported for other nerve stimulating procedures. However, the treatment was not compared for efficacy to standard medical therapies for chronic headache prophylaxis. The available data lacks large controlled placebo controlled studies demonstrating superior efficacy when compared to the current standard of care for chronic migraine headaches. Accordingly, the requested gammaCore vagus nerve stimulator is not likely to be more beneficial for treatment of this patients medical condition than standard available therapies. One reviewer found that the requested gammaCore vagus nerve stimulator is likely to be more beneficial for treatment of this patients medical condition than standard available therapies.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 overturned.Credentials/Qualifications:  One reviewer is board certified in neurology with subspecialty certification in pain management and is actively practicing. One Reviewer is board certified in neurology and is actively practicing.  One Reviewer is board certified in neurology 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

The parent of a five-year-old female enrollee has requested coverage for applied behavioral analysis (ABA) therapy for treatment of the enrollees autism. Findings:  The physician reviewer found that applied behavioral analysis has been shown to be effective in treating behaviors associated with autism spectrum disorder (Rogers et al., Warren et al. and Grey, et al.). Treatments based on operant principles of learning are more effective for reducing maladaptive behaviors than alternative treatments. Warren and colleagues reviewed 34 studies of early intervention in autism. They concluded that studies of Lovaas-based approaches and the Early Start Denver Model resulted in some improvement in cognitive performance, language skills, and adaptive behavior skills. Additional studies have shown that ABA methods continue to result in positive outcomes in individuals with autism and intellectual disability (Grey, et al.). Evidence-based studies also noted improvement of function in older children with autism spectrum disorders using intense ABA interventions (Granpeesheh, et al.). This patient was diagnosed with autism by the regional center based upon a developmental evaluation which documented significant deficits in communication, social interaction and play skills. The patients diagnosis of intellectual disability does not preclude her from potentially deriving benefit from ABA therapy. The proposed therapy will address behavioral concerns including daily living skills, socialization and language skills. Given the patients documented deficits in these functional areas, ABA therapy is medically appropriate and necessary in this case.
Appeal type: Medical Necessity
Decision: Upheld

The patient is requesting authorization and coverage for Otezla 30 mg tablets.Findings: Anti-tumor necrosis factor (TNF) agents have been proven very effective for psoriatic arthritis and are disease modifying agents. They prevent progression of disease, erosions and disability and are thus the preferred agent for psoriatic arthritis. Medical literature supports the use of conventional and biologic agents (anti-TNF agents) over the use of a targeted synthetic biologic such as Otezla (apremilast) for the treatment of psoriatic arthritis. A study states that at this time, apremilast should be reserved for patients unable to take disease-modifying antirheumatic drugs. In this case, the submitted documentation does not reflect that the patient has either failed or has a contraindication to conventional synthetic (csDMARD) and biological (bDMARD) disease-modifying antirheumatic drugs. Under these circumstances, the requested medication, Otezla 30 mg tablets, is not medically necessary for the patients medical condition.Final Result: The reviewer determined that the requested medication is not medically necessary for the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in internal medicine, and allergy and immunology, with subspecialty certification in rheumatology, 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.