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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for BRCA1 and BRCA2 sequence and deletion/duplication for evaluation of the enrollees risk of breast cancer. Findings:  The 3 physician reviewer found that the patient with a history of an ovarian polyp and right partial breast surgery for a benign radial scar. Her maternal grandparent had leukemia. Her parents have a history of colonic polyps. Her sister had a non-melanomatous skin cancer. The patient has requested authorization and coverage for BRCA1 and BRCA2 sequence and deletion/duplication. The Health Plan has denied this request as investigational. Per the National Comprehensive Cancer Network (NCCN) guidelines BRCA testing is indicated for an individual that has a personal history of any neoplasm, and has a first, second or third degree relative with breast, ovarian, pancreas or prostate cancer. The patient fails to meet this criteria. In addition, the U.S. Preventative Services Task Force recommend against routine testing unless there is a family history breast, ovarian, tubal or peritoneal cancer. For the reasons provided, the request for BRCA1 and BRCA2 sequence and deletion/duplication is not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: The 3 reviewers determined that the requested testing is not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewer number one is board certified in internal medicine with sub-specialty certification in medical oncology 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 medical oncology 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 medical oncology 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 61-year-old female enrollee has requested a cardiac computed tomography (CT) for evaluation of her chest pain. Findings:  The physician reviewer found that in this patients case, the currently accepted criteria for coronary CT angiography have not been met since the test was not used in lieu of an imaging stress test, the test did not demonstrate equivocal or discordant results by report, and there is no suspicion of congenital coronary anomalies. Applying the expert consensus guidelines endorsed by the American College of Cardiology Foundation Task Force on Expert Consensus Documents, coronary CT angiography is not clinically indicated in the setting of stress testing without equivocal or discordant stress test results. As such, the diagnostic procedure at issue was not medically necessary in the evaluation and treatment of this patients condition.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 2-year-old female enrollee has requested up to 2 hours per week of speech therapy and up to 10 hours per week of occupational therapy for treatment of the enrollees autism.  Findings:  The physician reviewer found that there is a long history of approaches used to intervene and facilitate development of adequate communication and interpersonal skills in children with autism. Typically, children on the autism spectrum require interventions in multiple areas, provided using a team approach, consisting of speech therapy, occupational therapy, and behavioral therapy. Fundamental to the diagnosis of ASD are deficits in speech and language. Most young patients with ASD benefit from therapies designed to improve their ability to communicate and engage in social interactions (Volkmar and colleagues). The authors found that, Research has shown that intervention makes a difference, and that early intervention focused on communication and social skills can significantly improve the outlook for individuals on the spectrum. Of import is that the deficits in the use of language can serve as major impediments to successful social adaptation and acceptance. Overall, the authors suggest that, The sooner and more aggressively these deficits are targeted, the better chance the child has for developing adequate skills to function in the community. As this patient exhibits significant deficits in expressive language, receptive language, and pragmatics, the requested speech therapy is medically necessary and appropriate for management of her deficits. Therefore, up to two hours per week of speech therapy is clinically indicated to address her delays and should be authorized.With regard to the requested occupational therapy (OT), Roley and colleagues noted that OT focuses on developing motor planning skills and self-help skills, developing age-appropriate communication skills (written and functional), processing information and regulating the response to incoming information. These goals address many of the deficits discussed by Case-Smith and Arbesman who noted that, Predominant characteristics of autism that are often the focus of intervention include limited social interaction, delayed or deficit language, behavioral problems, and sensory-processing difficulties. With regard to the necessity of therapy, the authors found that Children with ASD have a range of occupational and performance problems that interfere with their full participation in school, home, and community activities. For these reasons, OT is well-suited to affect positive change in children with ASD. This patient exhibits significant deficits in self help skills, fine motor skills, motor planning, and the processing of sensory information. The requested OT for up to 10 hours per week is therefore medically necessary and appropriate for this patient.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a six-year-old male has requested  speech therapy twice per week for one hour for treatment of his Prader-Willi Syndrome with speech language disorder.   Findings:  The physician reviewer found that based on review of the available records, this patient has an identified genetic syndrome that includes profound hypotonia with developmental issues involving gross motor, fine motor, and speech delays and speech articulation disorders. The American Academy of Pediatrics (AAP) guidelines for Prader-Willi Syndrome note anticipatory guidance includes speech therapy (McCandless, et al). Successful programs are designed and individually tailored to meet the childs functional needs and should be coordinated and integrated with educational and medical treatment plans (Michaud, et al). In addition, a longitudinal study of four years of speech therapy in a child with Prader-Willi Syndrome noted an increase in vocabulary, oral comprehension, and narrative abilities. The speech and language intervention was effective in multiple linguistic levels including phonological, syntactic, lexical and pragmatic abilities (Misquiatti, et al). This patient has significant articulation and pragmatic difficulties noted on speech and language evaluation, although no standardized methods were utilized during the testing. Given this patients noted difficulties and underlying diagnosis, speech therapy is medically necessary at the requested frequency of one hour sessions twice per week.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 59-year-old female who weighs 201 pounds and has a BMI of 39.3. The comorbid conditions reported included hyperlipidemia, hypertension and depression. The patient indicates that she has tried supervised and unsupervised weight loss programs and medications but has not achieved a sustained weight loss.  The patient has requested authorization for a laparoscopic Roux-en-Y gastric bypass. The Health Plan denied her request based upon a determination that the procedure is not medically necessary.With a BMI of 39.3 and comorbid conditions such as hypertension, hyperlipidemia, and depression, the patient meets nationally accepted medical necessity criteria for consideration of weight loss surgery. It is highly likely that gastric bypass surgery will be beneficial for this patient. Furthermore, the patient does not require further dietary workup prior to undergoing weight loss surgery. There is no scientific evidence demonstrating that structured diet or exercise plans have been successful in the treatment of the morbidly obese. In fact, the Swedish obesity study identifies that even though there may be reduction or resolution of some symptoms with diet and exercise, surgery has the longest and best long-term outcome for the morbidly obese.  The psychological evaluation indicates the patient is an appropriate candidate for the surgery.Based upon the information set forth above, I have determined the requested procedure is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential treatment center services. The Health Plan has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavioral health condition.Findings: The submitted documentation fails to demonstrate the medical necessity of the services at issue. The standard of care is to provide treatment in the least restrictive environment possible. By the date in question, the records demonstrate this patient did not have any suicidal or homicidal ideation. Although the patient has a chronically elevated risk of self harm due to his prior suicide attempt, the documentation does not report the patient was an imminent threat to himself or to others. The patient was not aggressive. The patient did not have major psychiatric symptoms of psychosis, mania, hallucinations, or delusions. The patient did not have any co-morbid substance use problems. The patient was cooperative and would participate in activities and therapy. The patients parents were supportive of the patient. The patient was able to attend to his activities of daily living. The patient did not require 24 hour supervision by the date in question. The patient could have been treated in a partial hospitalization program (PHP), which is a less restrictive environment when compared to residential treatment centers. Therefore, residential treatment center services were not medically necessary for treatment of this patients medical condition.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 expertise 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 authorization and coverage for the Intracept procedure (22899, C9752) at level L4-L5. Fischgrund and colleagues report that patients with Type I or Type II Modic changes treated with radiofrequency ablation of the basivertebral nerve for chronic back pain exhibited significantly greater improvement in Oswestry Disability Index (ODI) at three months and a higher responder rate than sham treated controls. The authors further noted that patients treated with radiofrequency ablation of the basivertebral nerve for chronic back pain exhibited sustained clinical benefits in ODI and Visual Analog Scale (VAS) and maintained high responder rates at two years following treatment. In this case, the patient has chronic low back pain with Modic endplate changes as shown on MRI. Given that current medical literature supports the clinical benefits and durability of the requested procedure for the treatment of isolated low back pain with Modic endplate changes, the requested service is medically indicated. Therefore, the Intracept procedure (22899, C9752) at level L4-L5 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 orthopedic 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 a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for advanced lipoprotein testing. Findings:  Three physician reviewers found that there is a lack of support for the services at issue in this clinical setting.  The current guidelines do not support use of the advanced lipid testing.  The medical evidence supports the use of standard risk factors and standard lipid profile to make decisions about lipid management.  In addition, the guidelines have moved away from specific target values and emphasize use of the pooled risk score analysis for decisions regarding statin therapy.  Thus, advanced lipoprotein testing performed was not likely to have been more effective than other methods of evaluating this patient. Final Result: 3 of 3 reviewers determined that 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. Credentials/Qualifications: All three physician reviewers are board certified in internal medicine with sub-specialty 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: Experimental/Investigational
Decision: Overturned

The parents of a two-year-old female enrollee requested authorization and coverage of an umbilical cord blood stem cell transplant without total body irradiation for treatment of the enrollees medical condition. The Health Plan denied the request indicating that the requested therapy is considered experimental for treatment of the enrollees acute lymphocytic leukemia.Three physician reviewers performed an experimental/investigational Independent Medical Review. All three physician reviewers concluded that the requested therapy is likely to be more beneficial for treatment of the enrollees medical condition than any available standard therapy. Because all three physician reviewers concluded that the requested therapy 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

A 53-year-old female enrollee has requested Celebrex for the treatment of her osteoarthritis. Findings:  The physician reviewer found that when Coumadin therapy is used, the concomitant use of platelet-inhibiting agents should be avoided, as this clearly increases the risk of unwanted bleeding. All traditional NSAIDs have varying degrees of anti-platelet activity and should not be used in a patient who is anticoagulated with Coumadin. However, COX-2 selective inhibitors do not have anti-platelet effects. Standard practice would be to recommend Celebrex (the only available selective COX-2 inhibitor) for patients who must also take Coumadin. While it is true that serious bleeding events have been reported in patients taking Celebrex and Coumadin, this has typically been due to inadequate monitoring of the patients INR. It is known that Celebrex will displace Coumadin from serum proteins, freeing more active Coumadin and raising the patients INR. The patients Coumadin dose will usually need to be lowered to maintain the desired INR. When done correctly with appropriate monitoring, the concurrent use of Celebrex is considered the best way to provide non-steroidal anti-inflammatory effect in patients requiring Coumadin therapy.
Appeal type: Medical Necessity
Decision: Overturned

A 60-year-old female enrollee has requested for one-on-one 50 minute psychotherapy sessions for treatment of her behavioral health condition. Findings:  The physician reviewer found that there is data to support the contention that for depression, a combination of psychotherapy and medication is preferable to either treatment alone. This is particularly true in the case of older adults and when selective serotonin reuptake inhibitors (SSRIs) are used (Cuijpers, et al.). Furthermore, some studies suggest that patient preferences for treatment should be taken into consideration (Pinquart, et al.). Given this patients previous positive experience with individual therapy, she is very likely to benefit from psychotherapy on an individual basis at the requested frequency.
Appeal type: Medical Necessity
Decision: Upheld

The patient is 56-year-old man who has a T1c No Mo cancer of the prostate. His Gleason score is 6(3+3). The patients PSA increased from 4.3 in August 2004 to 6.2 in November 2004. Results of core biopsies showed 1 of 7 containing less than 5% volume of cancer and 6 of 7 cores were benign. The patient has been offered conventional radiation therapy, intensity-modulated radiation therapy (IMRT) and brachytherapy (seeds). He prefers to undergo conformal proton beam therapy. The Health Plan has denied coverage for the requested therapy on the basis it is not medically necessary for treatment of the patients medical condition.Analysis and Findings:The patient has a low stage, low grade and minimal volume cancer of the prostate. This volume of tumor is small enough to be highly curable by conventional radiation therapy. IMRT is likely to cure the patient and will result in fewer side effects than conventional radiation therapy. Brachytherapy is also likely to be effective and carries less rectal side effects, but slightly more urinary side effects. In the case of this patient, there is no evidence proton beam therapy will result in a superior outcome to the other alternatives offered by the Health Plan. Furthermore, the side effects resulting from proton beam therapy are similar to those associated with IMRT. Thus, there is no clinical indication for proton beam therapy for treatment of this patients cancer. Therefore, I have determined that the requested therapy is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for sinus surgery prior to his current surgery date. The records provided for review document that this patient has experienced chronic sinusitis for several months. The patient has been treated with nasal and oral steroids as well as sinus irrigation and oral antibiotics. Sinus surgery for nasal polyps is a known treatment modality.  The records support surgical intervention. However, there is a lack of urgency documented to support an urgent change of the scheduled surgery to an earlier date. Therefore, the scheduling of sinus surgery prior to his current surgery date is not medically necessary for 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 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

A 56-year-old female enrollee has requested authorization and coverage for a power operated wheelchair for treatment of the enrollees ankle injury.  Findings:  The physician reviewer found that the documentation provided does not include a mobility evaluation. Accepted medical necessity criteria in this setting (Medicare guidelines) require that an individual undergo a mobility evaluation before the appropriateness of a power operated vehicle can be determined. Given the absence of a sufficient mobility evaluation, it is unclear whether the patient currently has mobility related activity of daily living (MRADL) deficits within the home. The presence and extent of such deficits must be documented in order to determine if a power wheelchair is necessary to ameliorate the patients mobility deficits within the home. Moreover, it is not clear that another assistive device would be insufficient to ameliorate any of the patients mobility deficits. Therefore, the Health Plans denial was appropriate and should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  The parent of an enrollee has requested shoe lifts for treatment of the enrollees medical condition.  Findings:  The physician reviewer found that Russell-Silver syndrome is a genetic syndrome characterized by intrauterine and postnatal growth retardation, short stature, craniofacial and body asymmetry, fifth finger clinodactyly, and congenital heart defects.  Leg length discrepancy is one of the main clinical features of this syndrome, and appropriate management at all levels is essential to the success of affected patients.  This patient has an almost 2 cm leg discrepancy, and according to the documentation submitted, may require limb equalization surgery at some point in the future.  However, at this time, he is able to participate in all appropriate activities with the aid of shoe lifts.  In order to facilitate functional progress and normalize his development and ambulation, shoe lifts were medically necessary for the treatment of this patient.  Final Result: The reviewer determined that the equipment 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 pediatrics with sub-specialty certification in pediatric critical care 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.