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

A 61-year-old female enrollee has requested for continued Skilled Nursing Facility (SNF) care for treatment of her  left bimalleolar fracture. Findings:  The physician reviewer found that this patient has significant co-morbid medical conditions including neuropathy, DM retinopathy, pleurisy, and a history of breast cancer, that all complicate her recovery from the ankle injury. Due to these co-morbid medical conditions, she requires a higher level of care than she could receive with PT and OT services at home.
Appeal type: Medical Necessity
Decision: Upheld

A 46-year-old male enrollee has requested magnetic resonance imaging (MRI) of the thoracic spine for an evaluation of his pain and osteoarthrosis. Findings:  The physician reviewer found that the patient clearly has a chronic set of symptoms which must have prompted the thoracic spine radiographs three years ago. The documentation in the medical record does not note any symptoms that would suggest a focal lesion that would require MRI for diagnosis (i.e., spinal tumor, epidural abscess, fracture, etc.). Further, the physical examination notes do not reveal any focal findings that would suggest a focal lesion. The Health Plans guidelines for the indications for MRI of the thoracic spine are consistent with good standards of medical practice. In addition, positive MRI findings are common, even in patients who are without symptoms.
Appeal type: Experimental/Investigational
Decision: Overturned

A 57-year-old female enrollee requested authorization and coverage of a Glucowatch. The Health Plan denied the request indicating that the requested equipment is considered experimental for treatment of the enrollees hypoglycemic unawareness.Three physician reviewers performed an experimental/investigational Independent Medical Review. All three physician reviewers concluded that the requested equipment 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 equipment is likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy, the Health Plans denial was overturned.
Appeal type: Medical Necessity
Decision: Overturned

The patients parent has requested reimbursement and prospective authorization and coverage for residential treatment center (RTC) services. The American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists Child and Adolescent Level of Care Utilization System (CALOCUS) provides a reliable framework for determining the appropriate level of care for adolescents needing mental health treatment. Using CALOCUS, providers score patients on a scale of 1-5 using a six-pronged Dimensional Rating System. The patient has a composite score which is consistent with medically monitored residence based services, similar to the services provided at the current RTC facility. Therefore, the RTC services were and are medically necessary for treatment of this patient. Final Result: The reviewer determined that the services at issue were and 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 with subspecialty certification in child and adolescent 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 patient has requested reimbursement for suction assisted lipectomy (CPT code 15877). The World Professional Association for Transgender Health (WPATH) lists chest surgery, creation of a male chest, as a medically necessary treatment for gender dysphoria. Olson-Kennedy and colleagues reported that chest surgery is a safe and effective treatment for gender dysphoria, noting, Chest dysphoria was high among presurgical transmasculine youth, and surgical intervention positively affected both minors and young adults. In this case, the patient had a diagnosis of gender dysphoria, and received liposuction as part of male chest reconstruction surgery to prevent dog-ears, a common complication of mastectomies. Given that the service at issue was part of a medically necessary gender affirming surgery, it was medically indicated. Therefore, suction assisted lipectomy (CPT Code 15877) was medically necessary for the treatment of this patient.Final Result: The reviewer determined that the service at issue was 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 with expertise in transgender health 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 15-year-old female enrollee has requested residential treatment center (RTC) mental health services for treatment of the enrollees behavioral health condition.  Findings:  The physician reviewer found that the residential treatment center (RTC) services provided from the date indicated forward were and are medically necessary for treatment of the patients medical condition. According to the documentation submitted for review, the patient does continue to meet criteria for treatment at the RTC level of care. The patient has poor-to-fair motivation, she is preoccupied with intrusive repetitive thoughts 4-6 hours a day and she is cooperative with highly structured treatment. Moreover, she needs supervision at all meals or she will restrict her eating. Some degree of external structure beyond self-control is required to prevent the patient from compulsive exercising. She is able to ask for and use support from others. In addition, she has severe family conflict that prevents her from receiving structured treatment in the home. For the reasons provided above, the RTC level of care provided from the date indicated forward were and are medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The parents of an 11-year-old male have requested growth hormone (GH) therapy with Humatrope for treatment of short stature.  Findings:  The physician reviewer found that the patients predicted adult height does not warrant GH therapy on the basis of idiopathic short stature, according to the 2003 FDA guidelines. Additionally, the patient had a normal IGF-1 level and the reports for GH stimulation testing are incomplete. Although the patient may have had growth-retarding therapy for his ADHD and gastrointestinal problems, the medical indication for GH therapy has not been adequately documented. The patients bone age and history of linear growth are unknown and laboratory testing is non-confirming.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 20-year-old female with myofascial pain and trigger point syndrome. She has requested authorization and coverage for Botox injections to her trigger points. The Health Plan has denied the request indicating the requested therapy is not medically necessary for treatment of the patients condition.The Health Plans denial should be upheld. Botox is currently FDA-approved for treatment of dystonia, spasticity, and blepharospasm. There are no peer-reviewed reports demonstrating long-term efficacy or safety of Botox for treatment of trigger point injections in cervical dystonia or myofascial pain syndrome. As such, conservative treatment modalities are likely to be more effective than Botox for treatment of the patients chronic pain. 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for nusinersen (Spinraza). Spinraza has U.S. Food and Drug Administration (FDA) approval for treatment of patients with SMA. Additionally, the medical literature reports positive health outcomes with use of Spinraza in this patient population. Data from researchers state that the sham controlled phase 3 clinical study ENDEAR was terminated early based on significantly favorable results in interim analysis. The authors reported that given the positive preliminary results, all patients were transitioned to receive Spinraza in an ongoing open-label, phase 3 study, SHINE, which will evaluate the long-term efficacy, safety and tolerability of the medication. All told, Spinraza is considered the standard of care for the treatment of SMA. Thus, the requested Spinraza is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Findings:  Three physician reviewers found the requested Spinraza is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested Spinraza is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Credentials/Qualifications: Physician reviewers 1 and 3 are board certified in neurology with sub-specialty certification in pain medicine and are actively practicing. Physician reviewer 2 is board certified in neurology with sub-specialty certification in pain medicine and is actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 52-year-old female enrollee has requested for Botox injections for treatment of her chronic pelvic pain and vaginismus. Findings:  Two physician reviewers found that botox is currently being investigated for the treatment of pelvic floor dysfunction. While there is some data suggesting that it may be helpful for the treatment of vaginismus, the short and long-term efficacy remains unproven. Risks and side effects are still being studied. At this time, there is no evidence that the proposed therapy is likely to be superior to standard treatments in this setting.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for endocardial implantation of a Watchman device. Findings:  The physician reviewer found that The records document that this patient had paroxysmal atrial fibrillation noted on an exercise test but not on the prior Holter examination. The patients CHADS-VASc score of 3 favors anticoagulation. He has no contraindications to anticoagulation therapy and no reported prior significant bleeding events. He has tolerated anticoagulation with Eliquis without complications. Currently, the Watchman device is recommended by the American College of Cardiology (ACC), American Heart Association (AHA), and Heart Rhythm Society (HRS) guidelines for use in patients who cannot tolerate or have a contraindication to anticoagulation therapy (January, et al). Anticoagulation therapy remains first-line therapy for paroxysmal atrial fibrillation in the setting of an elevated CHADS-VASc score in patients who can tolerate it without significant contraindications. This patient has no reported contraindications to anticoagulation therapy or complications. The medical literature and guidelines support continued medical therapy in this patients clinical setting over implantation of the Watchman device. Therefore, the requested endocardial implantation of a Watchman device is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Findings:  Two of the three physician reviewers found the requested endocardial implantation of a Watchman device  is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.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 subspecialty certification in cardiovascular disease 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

A 54-year-old female enrollee requested authorization and coverage of gastric bypass surgery. The Health Plan denied the request indicating that the requested procedure is not medically necessary for treatment of the enrollees morbid obesity. One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plans denial on the basis that the requested procedure is medically necessary pending confirmation of the enrollees body mass index.
Appeal type: Experimental/Investigational
Decision: Overturned

An enrollee has requested authorization and coverage for laparoscopic anti-reflux surgery utilizing LINX reflux management system. In this case, the persistence of symptoms and findings of esophagitis is suggestive of the development of Barretts esophagus. Persistence of these symptoms can result in complications of asthma including pneumonia and cardiac failure. Current data supports that medical therapies reduce acid production and do not correct the functional problem of lower esophageal sphincter incompetence. Surgical intervention can include fundoplication or magnetic sphincter augmentation with LINX. The procedures are comparable in reducing reflux, and have similar low complication rates. For these reasons, the requested laparoscopic anti-reflux surgery utilizing LINX reflux management system is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The 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: Physician reviewers 1, 2, and 3 are board certified in 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: Medical Necessity
Decision: Upheld

The parent of a 15-year-old male enrollee has requested a HIDA scan for evaluation of the enrollees abdominal pain. Findings:  The physician reviewer found that biliary dyskinesia is a potential cause of biliary colic in pediatric patients. A combination of symptoms and signs including abdominal pain, absence of gallstones, and abnormally low CCK-stimulated gallbladder ejection fraction are used to diagnose the disorder. In several small pediatric case series, cholecystectomy resulted in symptomatic improvement in the majority of patients with biliary dyskinesia. The possibility of biliary dyskinesia is a reasonable consideration in the differential diagnosis and should be ruled out. It appears the patient has not yet undergone a gastric emptying study and video capsule endoscopy. These procedures, which have been authorized by the Health Plan, are the next appropriate step in the diagnosis of the patients condition.
Appeal type: Urgent Care
Decision: Overturned

A 58-year-old male enrollee requested services on an emergent or urgently needed basis.  Findings:  The physician reviewer found that as a rule of thumb, a blood clot creates significant concern among laypeople. Although based upon the records provided the providers concern for DVT does not appear to be supported by the clinical findings, the average layperson cannot be expected to disregard the recommendation of his provider to seek immediate evaluation and/or treatment. A prudent layperson with an average knowledge of medicine who has been told by his health care provider that he requires a stat ultrasound to rule out a blood clot would reasonably expect the absence of immediate care to seriously jeopardize his health. All told, based upon the documentation provided for review, the patients symptoms met prudent layperson criteria for emergency care.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 6-year-old male enrollee has requested a replacement speech generating device for treatment of the enrollees autism, mixed receptive/expressive language disorder and pragmatic language disorder.  Findings:  The physician reviewer found that the submitted documentation establishes the medical necessity of the requested equipment. Speech generating devices (SGDs) are effective in improving speech in autistic children (Gadberry). This patient has been utilizing a SGD for 3 years, in which he has been successfully communicating with the device. A trial with the Accent 1000 was also successful. The patient needs a more powerful SGD as his need for communication expands. The survey by Gadberry reported that 15 percent of autistic children utilized aided augmentative and alternate communication devices successfully during music therapy. In addition, the review by Schlosser and Wendt noted that SGDs were successful in producing modest gains in autistic childrens speech without impeding speech production. All told, it is medically necessary that this patient receive a SGD.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 17-year-old female with left thigh pain and numbness. She was referred by her primary care physician to a neurologist for further evaluation. It was the primary care physicians assessment that the patient needed to see a neurologist. There are no treatment records since the initial visit with the primary care physician in January 2006. At issue is whether a neurology consultation is medically necessary for evaluation of the patients medical condition.Based upon the information provided, the patient has not received any care regarding her left thigh pain and numbness since January 2006.  The evaluating physician determined that neurologic consultation was medically necessary. In order to provide this patient with appropriate evaluation and treatment of her left thigh pain and numbness, a neurologic consultation is medically indicated and necessary. Accordingly, I have determined the requested consultation is medically necessary for evaluation of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Overturned

A 49-year-old male has requested coverage for a functional electrical stimulator (Bioness L300 neuromuscular electrical stimulation system) for treatment of his foot drop, secondary to multiple sclerosis.  Findings:  Two physician reviewers found that the patient has multiple sclerosis (MS). He has had difficulty with tingling, weakness, and gait. Foot drop has been observed. He has used an ankle foot orthosis (AFO), trekking poles, and a walker in the past. As a result of gait impairment, he has fallen, and sustained traumatic subdural hematomas requiring neurosurgical drainage. He has had treatment with Ampyra, Provigil, Keppra, and Neurontin. The provider notes show that the patient has had a trial with the Bioness L-300 neuromuscular electrical stimulator (NES), and his gait was reportedly much more stable than without it. He was noted to walk better than with his current AFOs, with more stable gait, and lower energy use. The Bioness L-300 was advised by his provider.This patient has had gait impairment with foot drop from multiple sclerosis, which has caused him to fall. The patients falls have resulted in traumatic brain injury in the past. The patients gait with his foot drop is noted to be insufficient, with notably increased fatigue and slowed walking speed. Research on the use of functional electrical stimulation (FES) devices has shown the potential benefits of walking speed, oxygen uptake and physiological cost in patients with spasticity from chronic central nervous system lesions, such as occurs in MS, brain injury or spinal injury (Paul, et al.). Studies have also shown the potential for neural plasticity, with functional gains maintained after discontinuation of FES devices (Sabut, et al.). This patient has had a trial with the Bioness L-300 and has been observed by his physical therapist to have improved gait stability and reduced energy use in walking when compared to his AFOs. Thus, the requested device is likely to be more beneficial for treatment of the patients medical condition than standard available therapy, including the use of AFOs and physical therapy.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 29-year-old female with a body mass index (BMI) of 49. She has many extensive comorbidities and has failed medical management. The patient has requested coverage for gastric bypass with duodenal switch. The Health Plan has denied the request on the basis the requested procedure is not medically necessary.The Health Plan has authorized medically appropriate treatment for the patient. Roux-en-Y gastric bypass is an accepted form of weight loss surgery for patients such as this patient. The patients obesity is likely to respond to Roux-en-Y gastric bypass. As such, use of the duodenal switch procedure is not medically warranted in this case. 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: Overturned

Nature of Statutory Criteria/Case Summary: an enrollee has requested authorization and coverage for pain management consultation. Findings:  The physician reviewer found that there is support in the medical literature for the requested consultation for pain management in this clinical setting. A consultation is a type of evaluation and management (E/M) service provided by a physician or other qualified health care professional whose opinion or advice regarding a specific clinical problem is requested by another physician or other appropriate source.  A consultation can be considered when there is a need to clarify a patients medical condition. A pain management evaluation would be expected to include a detailed musculoskeletal and neurological examination. Final Result: The reviewer determined that the requested services are medically necessary for the evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in physical medicine and rehabilitation and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.