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

The parents of a 15-year-old female enrollee requested authorization and coverage of eye surgery for treatment of strabismus.  The Health Plan has denied this request indicating that the requested surgery 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 procedure is medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for one-on-one applied behavioral analysis (ABA) support to be provided at school for treatment of the enrollees autism.  Findings:  The physician reviewer found that the request for one-on-one ABA support to be provided at school has been established as medically necessary for treatment of the patients autism. ABA is medically indicated for the treatment of children with autism. Studies shows that ABA started at a younger age provides improvements in cognitive skills, adaptive skills and language skills. In addition, the American Academy of Pediatrics state that for the management of children with autism spectrum disorder, a comprehensive program is important and that the program should be done in natural settings such as home and community as well as structured settings such as school. In this case, the patient has issues with non-compliance. In this clinical setting, one-on-one ABA support is appropriate in the school setting. However, the one-on-one ABA support should continue through the current school with the plan to transition the behavioral plan to the school team over the course of this school year. 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 pediatrics with sub-specialty certification in developmental-behavioral pediatrics and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 20-year-old female enrollee has requested intensive outpatient program level of care for treatment of her eating disorder. Findings:  The physician reviewer found that the submitted documentation does not support the medical necessity for intensive outpatient program services. There is no evidence of suicidality, and the patient has gained and maintained a satisfactory amount of weight.  There have been urges to binge and purge, but there is no indication of significant physiological compromise. The most recent information indicates that she was slightly above her ideal body weight. American Psychiatric Association guidelines recommend outpatient treatment for patients who are above 85 percent of their ideal body weight.  There is no indication of current coexisting medical, social or psychiatric conditions which would contraindicate a less intensive level of care.   All told, continuation of intensive outpatient program level of care was not and is not medically necessary for the treatment of this patient.  This patient could have been managed safely and effectively in the context of weekly one-hour mental health eating disorder outpatient therapy according to current evidence-based standards and expert consensus.
Appeal type: Experimental/Investigational
Decision: Overturned

A 46-year-old female enrollee has requested participation in a phase II clinical trial for the treatment of her systemic scleroderma. Findings:  Three physician reviewers found that this patients pulmonary fibrosis has progressed to where her chest x-ray has a ground glass appearance, her diffusion capacity has deteriorated, and she has worsening dyspnea despite supplemental oxygen. It is felt the patient has derived maximal benefit from past and current conventional therapies. Her records indicate she is a viable candidate for ASCT, which represents the best treatment alternative given this clinical scenario. Clearly, there are risks associated with participation in the clinical trial, but early data shows promising results.
Appeal type: Experimental/Investigational
Decision: Overturned

A 48-year-old male enrollee requested authorization and coverage of metal-on-metal hip surface replacement. The Health Plan denied the request indicating that the requested procedure is considered experimental for treatment of the enrollees hip osteoarthritis.Three physician reviewers performed a medical necessity Independent Medical Review. Two 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. One physician reviewer concluded that the requested procedure is not likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy. Because two of the 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: Upheld

A 63-year-old female enrollee has requested a stab phlebectomy for treatment of varicose veins.   Findings:  The physician reviewer found that the standard treatment regimen for varicose veins has several stages. Initially conservative therapy is offered to the patient, and if this is successful, then no further intervention is required. However, if conservative therapy fails, then high ligation, greater saphenous vein stripping or stab avulsions are generally recommended. New technologies are evolving to include radiofrequency ablation and endovenous laser therapy as treatment choices. In this instance, a three-month trial of compression hose with subsequent re-evaluation is a reasonable approach. The work up should include a duplex scan to rule out saphenous incompetence. Stab phlebectomy is not clinically appropriate at this stage.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for the contrast-enhanced coronary computed tomography angiography (CPT 75574) for evaluation of the enrollees heart disease status post chemotherapy for sarcoma. Findings:  The physician reviewer found that this patient has a rare primary malignant tumor arising in his heart. The current medical literature advocates the use of CT, magnetic resonance imaging (MRI), and transesophageal echocardiography in staging and surveillance after resection. In this case, the resection was subtotal indicating positive margins were left at surgery likely related to the difficulty in resecting this type of mass given the vital structures which are contiguous and/or inseparable from the mass. The coronary arteries are sensitive to the effects of radiation therapy and in order to deliver the radiation dose as safely as possible, the location and anatomic variants of the coronary circulation must be assessed prior to radiation therapy and then assessed after treatment in order to stratify risk. For these reasons, the contrast-enhanced coronary CT angiography (CPT 75574) was medically necessary for evaluation of this patients medical condition. Final Result: The reviewer determined that the diagnostic procedure at issue was 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 diagnostic radiology 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 neurofeedback for treatment of his traumatic brain injury. The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  This patient is status post traumatic brain injury and is requesting neurofeedback for treatment of his perceived cognitive deficits. Neurofeedback is not routinely use by neurologists or physiatrists, and there is a lack of support for the requested services in this clinical setting.  In this case, the patient is requesting this treatment based on his subjective impression he is having cognitive issues.  However, there is a lack of documentation of a problem which would necessitate the requested services.  Formal neuropsychological testing can help determine if the patient is having cognitive issues to determine the need for cognitive rehabilitation done by speech therapy or a neuropsychologist.  All told, the requested neurofeedback treatment is not medically indicated for the treatment of this patient. 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 neurology 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 Remicade for treatment of the enrollees neurosarcoidosis.  Findings: Two physician reviewers found that the medical literature supports the efficacy of infliximab for treatment of neurosarcoidosis when steroids have been unsuccessful. In this patients case, the patient has not responded to high dose of steroids. According to the treating provider, the patient has been on chronic steroids with insufficient improvement. There is clinical support of Remicade as an alternative therapy for treatment of neurosarcoidosis when other treatment options have not provided improvement. All told, the requested Remicade is likely to be more efficacious than the available standard therapy for treatment of this patient.Final Result: Two of three reviewers determined that the requested medication is 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: All three physician 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

A 48-year-old female enrollee has requested for Selective Internal Radiation Therapy (SIRT) for treatment of her rectal carcinoma, metastases to the liver. Findings:  Three physician reviewers found that the National Comprehensive Cancer Network guidelines for rectal cancer state that hepatic resection is a treatment of choice for resectable liver metastases from colorectal cancer. Furthermore, it states that ablative techniques may be considered when all known disease is amenable to ablation. These criteria are based upon the publication of Abdalla and colleagues. The guidelines for liver cancer include ablation or immobilization options. SIRT has been approved for both metastatic colorectal cancer to the liver as well as primary hepatocellular carcinoma. SIRT is a reasonable approach for this patient, and is likely to be more efficacious than alternative treatment options.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested physical therapy, occupational therapy and weekly massages for treatment of her medical condition.  The physician reviewer found that the patient sustained major vascular injuries in the left lower limb.  The laceration injuries were complicated by arterial clots further compromising blood flow to the distal left lower limb.  Vascular flow could not be re-established before significant tissue injury occurred.  Sequelae included myonecrosis of the lower leg muscles, compartment syndrome and deep peroneal nerve injury.  Notably, she underwent multiple debridements of the necrotic muscle tissue.  She has had residual left foot drop.  The patient has undergone inpatient and outpatient rehabilitation and has recovered modified independent ambulation using an ankle-foot orthosis and a cane.  She has maintained full passive range of motion and has been performing a home exercise program.  At this time, there are no expected health outcome benefits or functional benefits expected with further physical therapy, occupational therapy or massage therapy.  This patient has achieved maximal medical and functional benefit from therapy services.  She has had sufficient therapy to be independent with a stretching, strengthening and modality/self-massage program for maintenance of range of motion and slowly building up strength and endurance.  This patients clinical course and outcomes are not expected to be marginally improved with the proposed interventions.  All told, the requested physical therapy, occupational therapy and weekly massages are not medically necessary for the treatment of this patient.  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 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.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the residential treatment center (RTC) level of care services for treatment of his alcohol abuse. Findings:  The physician reviewer found that  on admission, the patient was not suicidal, homicidal, manic, or psychotic. His medical conditions were stable and managed on medications. He had no prior treatment at a lower level of care such as partial hospital program (PHP) or intensive outpatient program (IOP). No Clinical Institute Withdrawal Assessment (CIWA) was provided on admission, but his vital signs were stable and the withdrawal symptoms reported were not severe in nature. The medication changes that occurred did not require residential monitoring. The tremor reported was trace, he had no sweating, nausea, vomiting, diarrhea, or other gastrointestinal symptoms. There were no emotional, behavioral, or cognitive issues to warrant 24-hour level of care with medical and nursing supervision. The patient was motivated and he had sober supports in place. He could have received treatment at PHP level of care along with community supports in the form of a 12-step program with a sponsor, and continuation of care with his outpatient psychologist and psychiatrist. Final Result: The reviewer determined that the services at issue 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 with sub-specialty certification in addiction medicine 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: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for laboratory testing (CPT code 82542, column chromatography/mass spectrometry). The submitted documentation fails to demonstrate the superior efficacy of the services at issue. The test ordered is not a part of the diagnostic strategy or monitoring for the treatment of Lyme based on current guidelines. The diagnosis of Lyme disease is based on screening antibody testing and Western blot testing. The medical evidence does not support the services at issue in this clinical setting. Therefore, the superior effectiveness of laboratory testing (CPT code 82542, column chromatography/mass spectrometry) has not been established. Findings:  Three physician reviewers found the services at issue were 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.Final Result: The reviewers determined that the requested medication is 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: Physician reviewers 1 and 2 are board certified in internal medicine with sub-specialty certification in infectious disease and are actively practicing. Physician reviewer 3 is board certified in internal medicine. 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 reimbursement for wireless capsule endoscopy for evaluation of the enrollees abdominal pain. Findings:  2/3 of the physician reviewers found that the physician reviewer found this patient has had symptoms and biopsy findings suggestive of possible Crohns disease. Capsule endoscopy is useful for the diagnosis of Crohns disease or determination of the extent of disease activity, and has been demonstrated to be superior to radiographic imaging tests such as small bowel follow through. Capsule endoscopy has proven superior to current forms of radiological testing of the small intestine in detecting the mucosal abnormalities of non-stricturing Crohns disease. Per the study by colleagues, the frequency of small intestinal Crohns disease activity found by capsule endoscopy in a consecutive series was approximately double that detected by computed tomography enteroclysis, leading to change in management in a significant number of patients. In this patients case, wireless capsule endoscopy was likely to have been more effective than other available modalities for evaluating this patient.  Final Result: 2/3 of the 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: Physician reviewer number one is board certified in internal medicine with sub-specialty certification in gastroenterology 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.Physician reviewer number two is board certified in internal medicine with sub-specialty certification in gastroenterology 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.Physician reviewer number three is board certified in internal medicine with sub-specialty certification in gastroenterology 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:  The enrollee is requesting reimbursement  for partial hospitalization program (PHP) services. The enrollee has bipolar disorder and substance abuse.  He has a history of suicide attempts and abuse.  He transitioned to the partial hospitalization program (PHP) from a residential treatment center. A psychological evaluation indicated the enrollee had significant levels of anxiety. The therapist indicated the enrollee required 24-hour monitoring because he was at high risk for relapse. Documentation consistently reports no signs of suicidal ideation/homicidal ideation or psychosis. Previous or current treatment has not achieved complete remission of symptoms or optimal control of symptoms.  He attempted rehabilitation treatments in the past and has relapsed. The enrollees composite score is 19, which correlates with community based services. Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for Omnipod 5 G6 (Gen 5) system and pods. In this case, the patient has type 1 diabetes mellitus. A CGM log shows that, although reasonable overall, the patients recent glycemic control is not optimal based on the recent patterns indicating blood glucose 7% of the time in the very high category above the target range and 24% of time in the high category above the target range. In addition, there were wide fluctuations in blood glucose levels during the monitoring period. In this clinical setting, given that current medical literature supports the use of the requested equipment in improving both glycemic control for pediatric patients and the quality of life for them and their families, the requested equipment is medically indicated. Therefore, an Omnipod 5 G6 (Gen 5) system and pods are medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested equipment 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 pediatrics with sub-specialty certification in pediatric endocrinology 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.