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

Nature of Statutory Criteria/Case Summary: An enrollees parent has requested authorization and coverage for allergy laboratory testing (CPT-82784) (CPT-82785) (CPT-82787 x 4 units) (CPT-83520 x 4 units) (CPT-85025) (CPT-86001 x 11 units) (CPT-86003 x 41 units) (CPT-86008 x 64 units) (CPT-88184) and (CPT-88185 x 2 units). Findings:  The physician reviewer found that Current medical evidence has not established the efficacy of tolerance induction for the management of food allergies. Sicherer and Sampson note that the diagnosis of food allergy is largely reliant on medical history, tests for sensitization, and oral food challenges. The authors further note that management remains largely based on allergen avoidance. While it is standard of care to measure immunoglobulin E (IgE) levels to specific foods in question that the patient may have an allergic reaction to, there is a lack of support for an extensive array of blood tests examining foods to which the patient has not had a reaction. Additionally, there is a lack of support for oral desensitization to a multitude of foods to which the patient does not have a history of anaphylaxis. There is a lack of evidence in current medical literature supporting tolerance or sustained unresponsiveness with oral food desensitization. Therefore, allergy laboratory testing (CPT-82784) (CPT-82785) (CPT-82787 x 4 units) (CPT-83520 x 4 units) (CPT-85025) (CPT-86001 x 11 units) (CPT-86003 x 41 units) (CPT-86008 x 64 units) (CPT-88184) and (CPT-88185 x 2 units) is not likely to be more beneficial for evaluation of the patients condition than any available standard therapy.Findings:  Two of the three physician reviewers found the requested allergy laboratory testing (CPT-82784) (CPT-82785) (CPT-82787 x 4 units) (CPT-83520 x 4 units) (CPT-85025) (CPT-86001 x 11 units) (CPT-86003 x 41 units) (CPT-86008 x 64 units) (CPT-88184) and (CPT-88185 x 2 units) is not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the 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 reviewer 1 is board certified in allergy and immunology and is actively practicing. Physician reviewer 2 is board certified in board certified in internal medicine and allergy and immunology and is actively practicing. Physician reviewer 3 is board certified in allergy and immunology and pediatrics 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: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for tonsillectomy and adenoidectomy.  Findings:  The physician reviewer found that recurrent infection remains the most common indication for adult tonsillectomy. Other indications include cancer, asymmetric tonsillar growth, obstructive sleep apnea and peritonsillar abscess. According to the American Academy of Otolaryngology  Head and Neck Surgery, clinical indications for tonsillectomy include recurrent throat infection with documentation. Documentation for the recurrent throat infection indication would need to show a frequency of at least 7 episodes in the past year, or at least 5 episodes per year for 2 years, or at least 3 episodes per year for 3 years, with documentation in the medical record for each episode of sore throat and one or more of the following: temperature greater than 38.3C, cervical adenopathy, tonsillar exudates, or positive test for a group A beta-hemolytic streptococcal infection. In this case, there is no documentation in the family medicine or otolaryngology records of chronology of disease or treatment for recurrent tonsillitis for this patient. Therefore, the requested tonsillectomy and adenoidectomy are not medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the requested services are 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 otolaryngology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for calcitonin-salmon 200 unit spray (once daily x indefinitely). Findings:  The physician reviewer found that even though this patient has concerns for side effects from bisphosphonates, they are the therapy of choice in osteoporosis associated to HIV disease. Calcitonin has not been demonstrated to be very effective to decrease the risk of non-vertebral fractures. In addition, the patient should be evaluated to rule out secondary correctable causes of osteoporosis. The patient has a known history of a pathological fracture of ankle, thus, the treatment of choice is a bisphosphonate given monthly, like residronate, or annual intravenous zoledronic acid, which significantly decreases non-vertebral fractures. Final Result: The reviewer determined that the medication at issue was not and is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty 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 enrollee is requesting authorization and coverage for breast reduction surgery. The enrollee has a history of type 2 diabetes mellitus, hypertension, high body mass index, and symptomatic macromastia. A surgical consultation reported the enrollee had breast hypertrophy, which was causing upper back pain and interfering with her ability to exercise. She has indentations in her shoulders and wears two bras for support. She reported pain in her shoulders, neck, and back, recurrent rashes, shoulder grooves, and poor posture. The enrollee reports she is unable to exercise the way she would like because her breasts are too large. The enrollee reports that if she could be more active, she could better manage her diabetes and blood pressure, and she would be able to lose weight. This enrollee demonstrates classic symptoms of macromastia, and medical treatments have not improved her symptoms.  Symptomatic macromastia is a mechanical problem and conservative treatments have been shown to be ineffective for this condition. Surgery provides the only real chance for symptomatic relief. Literature reports breast hypertrophy has a significant impact on womens health status and quality of life. In women requesting surgery, non-surgical measures were not effective in providing permanent relief of breast-related symptoms. However, both pain and overall health status were markedly improved by breast reduction. A study showed reduction mammoplasty can be a motivation for post-operative weight loss, and these individuals were more physically active, had better glucose control and improved self-confidence.Final Result: The reviewer determined that the requested service is medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in plastic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Findings:  The physician reviewer found that An enrollee has requested authorization and coverage for lymph vein bridging anastomosis (lymphovenous bypass - CPT codes 38999, 38790, and 35226). The records document that this patient presents with progressive right upper extremity lymphedema secondary to breast cancer diagnosis and treatment. The patients provider has recommended treatment with lymph vein bridging anastomosis. Lymphaticovenular anastomosis for this patients arm edema is clinically appropriate and generally accepted as a potentially curative treatment for lymphedema. The patient is most likely to benefit from treatment before she develops progressive fibrosis that occurs with untreated chronic lymphedema. Winters and colleagues found that treatment with lymphaticovenular anastomosis is effective in reducing arm volume difference in patients suffering from breast cancer-related lymphedema. Cornelissen and colleagues concluded that lymphaticovenular anastomosis for early-stage breast cancer-related lymphedema resulted in a significant improvement in quality of life and a high rate in stocking discontinuation. Forte and colleagues reported that the maintained effectiveness of this treatment modality in long-term follow-up suggests great efficacy. Given this support, the requested lymph vein bridging anastomosis (lymphovenous bypass - CPT codes 38999, 38790, and 35226) is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings:  Three of the three physician reviewers found the requested lymph vein bridging anastomosis (lymphovenous bypass - CPT codes 38999, 38790, and 35226) 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.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested digital breast tomosynthesis for evaluation of the enrollees medical condition.  Findings: Three physician reviewers found that breast tomosynthesis is a technique that was developed several years ago as a problem solving adjunct to routine mammography.  Applying the same basic concept as computed tomography (CT) scanning, the logic is that by separating the various layers of breast tissue, one can better detect abnormalities.  This has been shown to be most useful in the evaluation of dense breasts.  In this patients case, the records noted extremely dense breast tissue.  It is specifically those patients who have dense breasts that can benefit most from breast tomosynthesis.  The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor.  Thus, breast tomosynthesis was likely to have been more effective than other modalities for evaluating this patient.Final Result: Three 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: All three physician reviewers 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: Upheld

A 63-year-old female enrollee has requested bilateral breast MRI for an evaluation of her breast screening. Findings:  The physician reviewer found that breast MRI is a useful adjunct to mammography and/or breast ultrasound in select patient populations. It is well documented in the peer-reviewed literature (including ACS guidelines, Medicare Coverage guidelines and ACR guidelines) that breast MRI is useful in screening patients with high risk of developing cancer (i.e., BRCA mutation, lifetime risk 20-25% as defined by BRCA pro or other models or those patients with history of radiation to the chest wall). However, as stated in the ACR Practice guidelines, breast MRI should not be used as a substitute for screening mammograms. Breast MRI is useful in evaluation of patients with crown breast implants when there is concern of implant rupture and as an adjunct to mammography. As this patient has breast pain with known implants and has not had a mammogram within the past few years, the appropriate imaging studies are mammography and breast ultrasound followed by breast MRI. This is the standard of care and the most appropriate option in this setting.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for occipital nerve block for treatment of the enrollees chronic migraine.  Findings:  Two reviewers found that the records indicate the presence of occipital neuralgia as documented by physical examination findings. However, occipital nerve blocks are not supported for the treatment of migraine or other type headaches. Occipital nerve blocks are supported for diagnostic purposes, and not supported for therapeutic treatment as there is a lack of long term benefit supported by peer reviewed literature. Cuadrado and colleagues noted there was no long term improvement of headache of chronic migraine type with use of occipital nerve block. A study noted that greater occipital nerve block does not reduce the frequency of moderate to severe migraine days in patients with episodic or chronic migraine compared to placebo. In addition, another study noted there was no long term improvement of headache of chronic migraine type with use of occipital nerve block. Final Result: Two reviewers determined that the requested service is 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: All three reviewers are board certified in neurology 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested digital breast tomosynthesis for evaluation of the enrollees breast cancer screening.  Findings: Three physician reviewers found that the diagnostic procedure at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. In this case, the patient has a residual mass, and tomosynthesis has been shown to better delineate and characterize a mass. This has been previously biopsied, and the pathological findings were sufficiently convincing to allow the residual mass to be left in place. Tomosynthesis better delineates the margins. Furthermore, it is specifically those patients who have dense breasts that can benefit most from tomosynthesis. The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor. For the reasons provided, the digital breast tomosynthesis was likely to be more beneficial for evaluation of the 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 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

The parent of a 10-year-old male enrollee has requested applied behavioral analysis (ABA) and intensive behavioral intervention (IBI) services for treatment of the enrollees autism. Findings:  Two physician reviewers found that the patient has a series of diagnoses including autism spectrum disorder (ASD), attention deficit hyperactivity disorder (ADHD), and serious behavioral problems of peer combativeness, authority conflict, and hiding. The literature shows that ABA therapy has at least a 40 year record of improvement in autistic children. The contention that ABA therapy is unproven or investigational is no longer prevailing opinion based upon multiple studies. While ABA therapy is a medically appropriate and indicated modality in this setting, based on the level of functional delays documented in the submitted records as well as his age, this patient does not require the frequency of therapy that has been requested. The proposed 20 hours of ABA therapy is generally indicated as early intensive intervention for younger patients. ABA therapy at a frequency of 10 hours per week is appropriate for this patient who has experienced some gains with treatment, but continues to have behavioral issues and problems with social interaction. A request has also been made for coverage of the patients participation in a six-week therapeutic summer camp program. The proposed program utilizes principles of intensive behavioral intervention (IBI) in an attempt to help children who experience social and behavioral difficulties. While there is little data studying the effects of such programs in this setting, given the patients documented issues with social interaction and acting out behaviors, his participation in a highly organized program directed at treating children with social and behavioral difficulties is a medically reasonable approach to treatment. Thus, the patient should also be covered for participation in the six-week therapeutic summer camp.
Appeal type: Urgent Care
Decision: Upheld

A 50-year-old female enrollee has requested for services she received in the Philippines indicating that her condition was  emergent or urgent in nature. Findings:  The physician reviewer found that the patient had low back pain and right groin pain radiating down her right leg. At that time, she was assessed with lumbar radiculopathy. The submitted records shows there is inadequate documentation of what the patient was told about her condition by the spine surgeon or the emergency department personnel in the Philippines to conclude that she reasonably believed she was experiencing an emergent or urgent medical condition. The clinical records available demonstrate that neither the MRI performed in the United States nor the MRI performed in the Philippines supports a diagnosis of cauda equina syndrome. Cauda equina syndrome is characterized by severe compression of nerve roots in the lumbosacral spine by a large disc herniation. The clinical findings include saddle anesthesia, urinary retention, overflow incontinence, impotence, bilateral leg pain and lower extremity weakness. There is substantial agreement that surgery should take place on an emergent basis for a diagnosis of cauda equina syndrome. There is insufficient documentation in the medical records from the Philippines that such a diagnosis was present. There is no documentation of the emergency room history or physical findings.
Appeal type: Medical Necessity
Decision: Overturned

A 33-year-old female enrollee requested authorization and coverage of a referral to a dermatologist for the treatment of moles.  The Health Plan denied the enrollees request indicating that the requested treatment is not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer overturned the health plans denial on the basis that the requested services are medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for midwife/nurse practitioner services at an accredited birthing center.Birth centers around the country provide antepartum and peripartum care for people with low-risk pregnancies who desire an out-of-hospital birth experience and who are expected to have an uncomplicated birth. For such people, birth center care can result in greater satisfaction and the same or better outcomes as an in-hospital birth. Through a thorough informed consent process, the patient and her provider are able to make a joint decision on birth expectation and contingency plans in order to deliver a child safely in this manner. People with low-risk pregnancies are candidates for birth center care. Generally, a female with a term singleton pregnancy in vertex presentation, and no medical or obstetric conditions that increase the risk for serious intrapartum or postpartum complications can be defined as low risk by criteria defined by the American College of Obstetricians and Gynecologists (ACOG). In this case, the patient has had an uncomplicated pregnancy. Additionally, there are no medical or obstetric conditions that increase the risk for serious intrapartum or postpartum complications. Therefore, midwife/nurse practitioner services at an accredited birthing center are medically necessary for the patients pregnancy.Final Result: The reviewer determined that the requested services are medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in obstetrics and gynecology 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.