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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for a connective tissue implant, nonhuman (including synthetic). Findings:  The physician reviewer found that there is a lack of data in current medical literature demonstrating the effectiveness of various biologic patches to augment the repair of large or complex rotator cuff tears. Micheloni and colleagues report that while the use of bioinductive implants could represent an effective aid in arthroscopic rotator cuff repair in selected cases and with the correct indications,  no current scientific evidence regarding such implants existed. In this case, an operative report reported that the patient underwent left shoulder arthroscopy for treatment of a massive rotator cuff tear involving the supraspinatus. In this clinical setting, there is a lack of data showing that the service at issue was an effective and/or safe treatment for the noted pathology, and the submitted documentation did not include compelling rationale or extenuating circumstances supporting the use of the service at issue. Therefore, the connective tissue implant, nonhuman (including synthetic) (CPT C1763) was not likely to have been more beneficial for treatment of the patients condition than any available standard therapy.Findings:  Two of the three physician reviewers found the connective tissue implant, nonhuman (including synthetic) (CPT C1763) at issue was not likely to have been more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the service at issue was not likely to have been 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 orthopedic surgery 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 tumor necrosis factor (TNF) antagonists lab testing for evaluation of the enrollees Crohns disease. Findings: Two reviewers found that the Prometheus Anser ADA test is a quantitative measurement of serum adalimumab (ADA) and anti-ADA antibodies. Some evidence exists that low serum levels of adalimumab and/or the presence of antibodies to adalimumab may play a role in primary or secondary response failures. Antidrug antibodies develop in a substantial number of patients and may be responsible for acute drug infusion reactions as well as delayed hypersensitivity reactions. In a large percent of patients who develop antibodies, such antibodies may disappear after continued treatment. The reasons for therapeutic failures remain unclear. Some evidence exists that low serum levels of adalimumab or the presence of ADA antibodies have an adverse effect on the clinical outcome of a patients response to treatment. However, there are few well controlled clinical trials to confirm that use of the Anser ADA testing leads to improved patient outcomes or quality of life as opposed to the standard method of treatment (Steenholdt, et al; Nanda, et al). Given the paucity of data demonstrating improved health outcomes with use of the Anser ADA test in this clinical setting, the TNF antagonists lab testing was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: Two reviewers determined that the testing at issue is 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: All three physician reviewers 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: Experimental/Investigational
Decision: Upheld

A 51-year-old male with metastatic thyroid cancer is requesting Cyberknife radiation therapy.  He has undergone the standard treatment modalities and has developed recurrent pelvic disease, which was evaluated by a specialist in orthopedic surgery/orthopedic oncology.Reviewers FindingsOne reviewer found that Cyberknife radiation therapy is appropriate for the needs of this patient. It can provide focused radiation to the tumor while sparing other pelvic structures.  This reviewer found that the Health Plan denial should be overturned.  The other two reviewers found that this is the first time radiation treatment will be utilized for the pelvic site. As such, the patient can be reasonably treated with conventional irradiation techniques.  These reviewers found that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 16-year-old female enrollee has requested residential treatment center services for treatment of the enrollees bulimia nervosa, depression, and anxiety.  Findings:  The physician reviewer found that applying the American Psychiatric Association (APA) practice guidelines, the RTC services provided to this patient from the date indicated forward are supported as medically necessary. The records document that the patient had suicidal ideation on admission with passive suicidal ideation since that time. The patient has demonstrated poor motivation and was noted on several occasions to have been unwilling to discuss her problem behaviors. In addition, she has been documented to need constant supervision due to compulsive exercising. Further, she continues to be preoccupied with repetitive intrusive thoughts 4-6 hours per day. She has struggled with anxiety and mood lability throughout her treatment. Her psychiatric medications have been increased and changed to maximize control of her symptoms. Overall, this patient has numerous characteristics of her eating disorder that suggest a worse long-term prognosis including onset below or at age 12, comorbid psychiatric issues, and suicidal ideation. It is also well documented that patients with bulimia have more self-injurious behaviors such as cutting, and have more character pathology and are more difficult to treat. She has failed treatment in the past in less restrictive settings and is undergoing severe psychosocial stressors that she is unable to adequately cope with. In summary, the RTC services provided from the date indicated forward were and are medically necessary in order to treat this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 61-year-old female enrollee requested surgery to remove abdominal adhesions and/or Suboxone for medical treatment of her pelvic pain.   Findings:  The physician reviewer found that the patient is at high risk for complications with another operation. When adhesions are lysed, generally more develop, so this is not recommended. In addition, her pain predates the development of her adhesions, and has continued despite repeat surgeries. With regard to the request for Suboxone, considering the length of time the patient has been treated with narcotics, the medications may actually be contributing to her pain. Further, the U.S. Food and Drug Administration (FDA) has not approved Suboxone for the treatment of chronic pain in this clinical setting. Consistent with these findings, there are multiple FDA approved treatments available to this patient for pain management and she should continue to explore these options with her providers. However, the requested surgery to remove abdominal adhesions and/or Suboxone is not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 63-year-old male enrollee has requested for telephonic PTSD/grief counseling for treatment of his depression, anxiety and agoraphobia. Findings:  The physician reviewer found that there is evidence in peer reviewed literature in support of psychotherapeutic interventions by telephone. Psychotherapy conducted over the telephone has received increasing amounts of empirical attention given practical advantages that side-step treatment barriers encountered in traditional office based care.treatment barriers common to older adults suggest that telephone therapy may be an efficient and effective mental health resource for this population. (Mozer, et al.). Mozer, et al. also noted that psychotherapy conducted over the telephone offers advantages to patients including increased access to and increased comprehensiveness of care. Another study examining the efficacy of telephone administered cognitive behavioral therapy (CBT) for 10 sessions targeting PTSD, depression and distress symptoms utilizing a randomized clinical trial found the use of this treatment modality via telephone to be beneficial. In conclusion, a trial of psychotherapeutic intervention by telephone is medically necessary for this patient and may help reduce symptoms and engage the patient in treatment.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 59-year-old female with a body mass index (BMI) of 52.4. She has multiple comorbidities including asthma and peripheral vascular disease. The patient has outlined failed attempts at weight loss with both supervised and unsupervised programs. She has requested authorization for a bariatric surgery consultation. The Health Plan has denied this request citing a lack of documented evidence the patient has participated in a medically supervised nutrition and exercise program.With a BMI of 52 and comorbid conditions, the patient meets nationally accepted medical necessity criteria for consideration of weight loss surgery. It is not likely that she will be able to lose weight and maintain the weight loss through non-surgical means. Furthermore, there is no scientific evidence demonstrating that structured diet or exercise plans have been successful in the treatment of the obese. In fact, the Swedish obesity study identifies that even though there may be reduction or resolution of some symptoms with diet and exercise, surgery has the longest and best long-term outcome for the obese.The patient needs to be evaluated by a bariatric surgeon to determine whether she should proceed with weight loss surgery. Thus, a consultation with a bariatric surgeon is medically indicated and necessary for treatment of this patients morbid obesity.Based upon the information set forth above, I have determined that the requested consultation is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. In addition, if upon consultation with a bariatric surgeon weight loss surgery is recommended and the patient undergoes a formal psychological evaluation and is found to be an appropriate surgical candidate, weight loss surgery should be authorized.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a four-year-old male enrollee has requested applied behavioral analysis (ABA) therapy for treatment of his pervasive developmental disorder, not otherwise specified (PDD-NOS). Findings:  The physician reviewer found that the medical literature strongly supports the treatment of autism spectrum disorders with ABA therapy. ABA therapy has a 40-year record of substantially improving motor, verbal and social interactive skills in autistic children and autistic children who received ABA therapy demonstrated significantly improved behavioral outcomes as compared to autistic children who did not receive ABA therapy (Myers, et al.). Additionally, Brosnan and Healy have indicated that ABA therapy is highly effective in reducing or eliminating aggressive behavior across a range of ages and degrees of development. Another meta-analysis reports that long-term comprehensive ABA intervention leads to positive effects, in terms of intellectual function, language development, acquisition of social skills, and acquisition of focusing skills (Virues-Ortega). The request for ABA therapy is medically reasonable and appropriate in this setting.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a partial responder to anti-viral therapy for chronic hepatitis C, but was unable to achieve a sustained viral response, resulting in relapse within 12 weeks of concluding a year-long course of optimal therapy. A request has been made for further treatment with Peg-Intron and ribavirin. The Health Plan has determined the requested therapy is not medically necessary.The treatment of patients with hepatitis C not achieving a sustained viral response is controversial and remains unproven at this time. Re-treatment is being advocated by some, but there exists no controlled trial or other compelling evidence that would make this approach the standard of care or medically necessary. While this may change in the future, currently there is insufficient evidence of success with the proposed management strategy. Therefore, I have determined the requested therapy is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement of the subacute detoxification treatment provided. Her diagnoses are alcohol use disorder and depressive disorder unspecified. On admission, the patient was not a danger to herself or others. The history given was consistent with daily alcohol consumption however her clinical presentation did not reach the severity of that consistent with the need for a medically intense 24/7 managed detoxification. There were no emotional, behavioral, or cognitive factors, which would warrant this level of care for her detox. Although described as having poor impulse control, there were no clear examples of this described. She was not manic, psychotic, or aggressive. She showed a pattern of difficulty remaining sober however that on its own is not reason for an inpatient detox setting, especially as the patient herself expressed motivation. She was medically and psychiatrically stable. There is no established history of delirium tremens (DTs).Final Result: The reviewer determined that the requested services 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

The parent of a five-year-old female has requested home based, individual speech therapy for one hour per week for treatment of her autism.  Findings:  The physician reviewer found that review of the submitted documentation demonstrates that this patient has been diagnosed with autism with clear evidence of receptive and expressive language delays. The relevant scientific literature reveals that plasticity in the developing brain still exists, even in the presence of underlying neurologic disease, and can be utilized to improve overall neurologic health. Thus, specific treatment including modalities such as speech therapy can be used to help induce brain plasticity, with the ultimate goal of retraining neural circuitry not compromised by the underlying pathogenetic processes that give rise to expressive and receptive speech delay. Therefore, individual speech therapy for one hour per week is medically appropriate and necessary for treatment of the patients medical condition. However, the submitted evidence does not document any barriers to receiving services outside the home. As such, it is not medically necessary for the patients speech therapy to be home based.
Appeal type: Medical Necessity
Decision: Upheld

A 58-year-old female enrollee requested compounded fluoxetine (Prozac) 20 mg (twice a day) for treatment of her major depressive disorder, recurrent, moderate. Findings:  The physician reviewer found that the patient indicates that she is allergic to both brand name and generic forms of fluoxetine (Prozac) and thus needs compounded versions. She reports that with generic Prozac she experienced hair loss. However, there are no specifics from the provider regarding the nature or severity of the patients allergy to brand name Prozac. Without documentation of the allergy, compounded Prozac is not medically necessary in lieu of standard brand name Prozac. For these reasons, the requested compounded Prozac is not medically necessary for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for digital breast tomosynthesis for evaluation of a breast screening mammogram. Findings:  The physician reviewer found that the report noted fatty tissue but no evidence of cancer. The Health Plan has denied reimbursement for digital breast tomosynthesis.  Per the Health Plan, the service at issue was investigational for the evaluation of this patient. Breast tomosynthesis provides advantages to radiologists interpreting mammograms, especially in women with dense tissue.  This tomographic method often allows the reader to separate dense glandular elements from underlying mass/architectural distortion, resulting in a decrease in callbacks and increase in diagnostic accuracy and detection of small cancers compared to two dimensional imaging alone.  Thus, the addition of digital breast tomosynthesis to the usual two dimensional protocol was likely of greater benefit to the patient than had her examination been performed using two dimensional imaging alone. Final Result: The reviewers determined that the service 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: Reviewers 1, 2, and 3 are board certified in diagnostic radiology 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

The parent of a 13-year-old female enrollee has requested resumption of in-home nursing care for treatment of the enrollees cerebral palsy, epilepsy, gastrostomy care, and failure to thrive.  Findings:  The physician reviewer found that based on review of the available records, the patients multiple and complex medical conditions are unstable and require the skills of a trained licensed nursing professional to provide intermittent care. The patients disorder necessitates ongoing collaborate care by different healthcare professionals (Turkelson, et al). According to the Centers for Medicare and Medicaid Services (CMS), skilled nursing care is considered medically necessary when the services could not be provided safely by non-medical personnel. Given the patients unstable medical condition, ongoing skilled nursing care is supported medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 41-year-old male with a lengthy history of documented low back pain and bilateral lower extremity pain. The patient is seeking spinal decompression surgery. The information submitted provides no clinical evidence or any other objective data, which would indicate that the proposed surgery is medically necessary. The information submitted provides no evidence that the proposed surgical intervention is indicated for this patient. No objective clinical information has been provided demonstrating why the proposed surgery is indicated. In fact, based upon the information provided, it is unlikely that the procedure would provide the patient any benefit. The proposed surgery would not be considered standard of care for this patient. Therefore, 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: Medical Necessity
Decision: Upheld

The mother of an eight-year-old male enrollee requested authorization and coverage of ongoing speech therapy. The Health Plan denied the request indicating that the requested therapy is not medically necessary for the treatment of the enrollees language disorder.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested therapy is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

A 38-year-old female enrollee requested authorization and coverage of vein ligation and stripping. The Health Plan denied the request indicating that the requested procedure is not medically necessary for treatment of the enrollees varicose veins.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested procedure is not medically necessary.
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: Two physician reviewers found that breast tomosynthesis was likely to be more beneficial for this patient than any available standard modalities. Medical studies have shown that the addition of three-dimensional (3D) digital breast tomosynthesis (DBT) reduces false positives and increases cancer detection when compared to two-dimensional full field digital mammography (FFDM, 2D) alone. Recall rates are reduced by 15-17%: 3D allows for separation of structures to differentiate architectural distortion from masses and overlapping fibroglandular tissue (asymmetries). Studies have also shown that there has been an increase in cancer detection by 33-53%: cancer detection increased from 6 cancers/1000 women screened with 2D to 8 cancers/1000 women screened with 3D. Three-dimensional DBT allows better characterization of possible masses, spiculation, and architectural distortion. In sum, there is sufficient evidence supporting the use of tomosynthesis for this patients routine breast cancer screening.  Final Result: Two 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: All three physician reviewers are board certified in diagnostic radiology and are 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.