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

Nature of Statutory Criteria/Case Summary: The patient has low back pain that has been present since November 2018. The patient rated his back pain as seven out of 10. On that date, physical examination findings indicated no focal neurologic deficits. The patients symptoms have persisted despite treatment with physical therapy and non-steroidal anti-inflammatory drugs. Magnetic resonance imaging of the lumbar spine demonstrated a L5-S1 disc bulge and facet arthropathy without neural compression. At issue in this case is whether a visit with a neurosurgeon specialist is medically necessary for the treatment of this patients medical condition. Referral to a neurosurgeon specialist is recommended in cases of low back pain that is severe and persists longer than 12 weeks, even when there are no red flags on examination. In this case, the patients physical examination was within normal limits with no focal neurologic findings. The provider noted that the patients low back pain has persisted out of proportion to the imaging results and physical examination findings. Moreover, a course of conservative therapy has not produced improvement. Thus, a referral to a specialist in diseases of the back, such as a neurosurgeon, is the next logical step in evaluation and management of the patients low back pain. Accordingly, the requested visit with a neurosurgeon specialist is supported as medically necessary for evaluation of this patients low back pain. Final Result: The reviewer determined that the requested service 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 family practice 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 an endobronchial valve device placed for treatment of her medical condition.  Findings:  Two physician reviewers found that the use of endobronchial valve device has shown to be safe in the medical literature. Researchers studied the safety and effectiveness of bronchial valves for the treatment of severe emphysema. The results confirmed an improvement in the quality of life scores and treated lobes decreased in size from baseline. In addition, another research study included 220 patients randomized to an endobronchial valve or standard medical therapy. The study noted improvements with forced expiratory volume in 1 second (FEV1) increase and walking distance. More relevant to this case was the identification of a subset of patients who did very well. The differentiation was the degree of lung heterogeneity present. When all the lung tissue was emphysematous, results were poor.  When some of the lung was free of disease results were much better. The meta-analysis concluded that there was documentation of statistically significant improvement in FEV1, dyspnea score, cycle ergometry and walking distance. In this case, endobronchial valve device placed was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.  Final Result: Two reviewers determined that the services at issue were likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications:   One reviewer is board certified in internal medicine and pulmonary disease and is actively practicing. Two reviewers are board certified in general surgery and thoracic surgery with sub-specialty certification in vascular surgery 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.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested digital breast tomosynthesis for evaluation of the enrollees risk for breast cancer. Findings: Three physician reviewers found that in the peer-reviewed medical literature, Skaane and colleagues found that the addition of three-dimensional digital breast tomosynthesis to two-dimensional full field digital mammography resulted in a significantly higher cancer detection rate and enabled the detection of more invasive cancers. Thus, although additional studies are needed to confirm these findings, there is adequate data to support the utility of three-dimensional digital breast tomosynthesis in this clinical setting. For these reasons, the breast tomosynthesis was likely to be more beneficial for evaluation of this patients medical condition than any available standard therapy.Final Result: Three reviewers determined that the diagnostic procedure 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 diagnostic radiology and are actively practicing. The reviewer 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

A 49-year-old female enrollee requested an in-lab sleep studyfor medical evaluation of her history of snoring, witnessed pauses in breathing at night, and non-arteritic anterior ischemic optic neuropathy.   Findings:  The physician reviewer found that this patients records document a history of poor sleep, snoring, and witnessed pauses in breathing at night, as well as non-arteritic anterior ischemic optic neuropathy.  The provider noted concern that the patient is at risk of OSA.  Further, the patients co-existing medical conditions support the utility of a lab sleep study in lieu of a home sleep study.  Based on these findings, the requested laboratory sleep study for OSA is supported as medically necessary for evaluation and treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A fifty-nine year-old morbidly obese female with multiple comorbid conditions is requesting authorization to undergo gastric bypass with duodenal switch.  The patient has tried and failed multiple attempts at weight loss, and has obtained psychological clearance for weight loss surgery.  Reviewers Findings:The reviewing physician found that the patient is an appropriate candidate for surgical intervention.  And that duodenal switch is an accepted and necessary procedure for this patients medical condition.  Therefore, the reviewing physician found that the Health Plan denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for implantation of a hypoglossal nerve stimulator. Obstructive sleep apnea (OSA) is an increasingly prevalent clinical problem with significant effects. Continuous positive airway pressure (CPAP) has demonstrated excellent efficacy and safety for treatment of OSA. In patients who do not tolerate CPAP and fail to improve with an oral appliance, surgical intervention may be required. Although traditional upper airway surgical procedures target the anatomic component of obstruction, upper airway stimulation tackles the twin goals of improving anatomic and neuromuscular pathology. As reported in the published medical literature, the STAR trial demonstrated that hypoglossal nerve stimulation led to significant improvements in objective and subjective measurements of the severity of OSA. The authors reported the hypoglossal nerve stimulator is safe and effective in patients with OSA who have nonconcentric airway collapse, an apnea/hypopnea index (AHI) between 20 and 50, and a body mass index (BMI) less than 32. This patient meets the criteria for the requested procedure with an AHI between 20 and 50, a BMI of less than 32, and nonconcentric airway collapse. Moreover, he has failed CPAP, which is the gold standard treatment for OSA, and treatment with an oral appliance. For these reasons, implantation with a hypoglossal nerve stimulator is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.One reviewer found that implantation with a hypoglossal nerve stimulator is not 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 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 otolaryngology with subspecialty certification in plastic reconstructive surgery and is actively practicing. One Reviewer is board certified in otolaryngology and is actively practicing.  One Reviewer is board certified in otolaryngology with subspecialty certification in sleep medicine 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

Nature of Statutory Criteria/Case Summary: The patient is a transgender female who was diagnosed with gender dysphoria. The patient reported that she was interested in voice training. Per the submitted documentation, the patient began hormone therapy, but her gender dysphoria persisted due to the low pitch of her voice, which manifests as anxiety, depression, and agoraphobia. The patient requested authorization and coverage for vocal therapy consisting of (office/outpatient visit new), (laryngoscopy telescopic), (speech/hearing therapy), (laryngeal function studies), and/or (behavioral quality analysis voice). The Health Plan denied the request and reported the requested services are not medically necessary for the treatment of this patient. At issue in this case is whether vocal therapy consisting of (office/outpatient visit new), (laryngoscopy telescopic), (speech/hearing therapy), (laryngeal function studies), and/or (behavioral quality analysis voice) is medically necessary for the treatment of the patients medical condition. Voice and communication therapy is a treatment option for transsexual, transgender, and gender nonconforming patients in order to maximize their overall health, psychological well-being, and self-fulfillment In this case, the patient endorsed persistent gender dysphoria due to the low pitch of her voice, which manifests as anxiety, depression, and agoraphobia. The medical evidence supports the requested services in this clinical setting. Therefore, vocal therapy consisting of (office/outpatient visit new), (laryngoscopy telescopic), (speech/hearing therapy), (laryngeal function studies), and/or (behavioral quality analysis voice) is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested service 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 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 53-year-old female enrollee requested authorization and coverage of wireless capsule endoscopy. The Health Plan denied the request indicating that the requested procedure is considered experimental for evaluation of the enrollees abdominal pain.Three physician reviewers performed an experimental/investigational Independent Medical Review. All three physician reviewers concluded that the requested procedure is likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy. Because all three physician reviewers concluded that the requested procedure is likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy, the Health Plans denial has been overturned.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:The patient has requested authorization and coverage for individual weekly therapy appointments, or any frequency of weekly therapy appointments. Based on the available records provided for review, weekly individual psychotherapy is reasonable and meets medical necessity criteria for this patient per American Psychiatric Association (APA) guidelines. The provider documented that the patient is experiencing acute anxiety and an exacerbation of post-traumatic stress disorder (PTSD) symptoms that interfere with her ability to function. In addition, cognitive behavioral therapy (CBT) remains the gold standard for the treatment of acute anxiety disorders. CBT is a time limited treatment and consensus guidelines recommend up to 15 weekly sessions. Given this patients symptoms, weekly individual therapy appointments are appropriate for this patients PTSD and acute stress. A review of randomized placebo-controlled trials provides strongly support the efficacy of CBT as an acute intervention for adult anxiety disorders, especially PTSD. Given this support, the requested individual weekly therapy appointments are medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in 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

A 23-year-old male enrollee has requested inpatient psychiatric hospital services for treatment of his bulimia nervosa, non-purging type. Findings:  The physician reviewer found that modern psychiatric practice aims to place patients in the least restrictive treatment setting.  In general, community intervention settings are thought to offer optimization of treatment gains.  However, placement in more restrictive settings is often clinically appropriate.  In this particular case, acute hospitalization was indicated.  On the date specified, the patient remained depressed and suicidal with auditory hallucinations.  The patient was experiencing acute-on-chronic pain and a heightened basal anxiety titer in anticipation of an upcoming conservatorship hearing.  In sum, the patient was not psychiatrically stable and discharge on the date specified would not have been medically appropriate.  The patient had reassuring laboratory findings on a subsequent date.  Following the legal determination, the patient commented that this depression was better and hallucinations were absent.  He had a sustained trend of eating 100% of his meals.  He did not display any behavioral difficulties in the treatment venue.  The complexity of the medication regimen did not exceed a threshold of unsuitability for a less restrictive treatment setting.  Although still enduring concerning symptomatologies, there was no description of an acute psychiatric syndrome or imminent threat to self or others.  Accounting for the history, hospital course and documentation provided, transfer to a less restrictive setting was indicated on the date indicated.   Thus, inpatient psychiatric hospital services rendered at the facility in question from the time frame specified were medically indicated.  The submitted documentation does not demonstrate the medical necessity of inpatient psychiatric hospital services from the date indicated forward.  Thus, a portion of the services at issue was medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/ Case Summary:  The enrollee requested reimbursement for the Decision DX-Melanoma assay. The enrollee has malignant, residual invasive melanoma on his left anterior thigh. The residual component showed a Breslows depth of 1.35 millimeters and is not associated with any of the abundant background biopsy site changes. A prior shave showed a Breslows depth of at least 3.5 millimeters. As the residual invasive component does not exceed that of the prior biopsy, the prior staging parameter remains unchanged. The Castle Biosciences report indicated the melanoma class was 2 and sub-class was 2B. A class 2B signature is associated with the highest risk of recurrence within five years. The Decision DX-Melanoma assay is not known to be effective based on a lack of scientific evidence showing that the results will accurately guide care and health outcomes. The use of this testing is not supported by scientifically based guidelines of national medical research or governmental agencies. Professional guidelines report routine genetic testing of primary cutaneous melanomas is not recommended outside of a clinical study. Current evidence does not support increased surveillance imaging as a result of gene expression profiling (Decision DX Melanoma assay) tests. Similarly, treatment and follow-up recommendations are not likely to change as a result of gene expression profiling (Decision DX Melanoma assay) results until studies have confirmed a benefit and adjuvant therapy has demonstrated a meaningful impact in earlier-stage disease.Final Result: Three of the three reviewers determined that the requested services were not likely to have been more beneficial than any available standard therapy for treatment of the enrollees medical condition. Credentials/Qualifications: Three reviewers are board certified in dermatology 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.
Appeal type: Experimental/Investigational
Decision: Overturned

A 55-year-old male enrollee has requested left total ankle replacement for treatment of his progressive osteoarthritis of the left ankle. Findings:  Two physician reviewers found that total ankle replacement (arthroplasty) is an appropriate surgical treatment in patients with severe inflammatory arthritis of the ankle joint. This is especially true when there is significant involvement of the subtalar joints, as is the case with this patient. Recent studies demonstrate positive intermediate-term results in this subset of patients when treated with total ankle arthroplasty. As reported by Haddad and colleagues, The five-year implant survival rate was 78%...and the ten-year survival rate was 77%. Regarding this particular patient, magnetic resonance imaging (MRI) revealed significant subtalar and midtarsal changes. In addition, the provider noted decreased range of motion, and increased pain and tenderness in the subtalar joints on physical examination. These clinical findings support diagnoses of inflammatory arthritis and arthritis in adjacent joints. Even separately, each of these diagnoses is sufficient to support the likelihood that the requested surgery is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Ozempic. Findings:  The physician reviewer found that the patients records document a history of obesity, prediabetes, and hyperlipidemia. As part of his treatment regimen, the provider has recommended treatment with Ozempic. While lifestyle modification is recommended as the cornerstone of obesity management, many patients do not achieve long-lasting benefits due to difficulty with adherence as well as physiological and neurohormonal adaptation of the body in response to weight loss. There are currently multiple pharmacologic therapies which are available for weight management (Gadde, et al.). Ozempic is a member of a class of medications known as glucagon like peptide 1 (GLP-1) analogs, which have been demonstrated to improve glycemic control as well as reduce body weight and decrease cardiovascular risk (Knudson and Lau). Multiple studies have shown that Ozempic is a safe and effective agent used to promote weight loss, via reduced appetite and energy intake, and delayed gastric emptying (Cornell). In this clinical setting, this patient is an appropriate candidate for treatment with Ozempic. Given these findings, the requested Ozempic is medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested medication 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 internal medicine with subspecialty certification in endocrinology, diabetes, and metabolism 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 two-year-old male enrollee has requested  coverage for speech therapy for treatment of the enrollees speech delay. Findings:  The physician reviewer found that according to Law and colleagues, approximately 6% of children have speech and language difficulties.  The authors noted that children whose difficulties persist into primary school may have long-term problems concerning literacy, socialization, behavior, and school attainment.  Bernhardt and Major concluded that results suggest that early phonological and metaphonological intervention can promote normalization of speech development and normal acquisition of literacy skills for some children with a history of severe phonological impairment.