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

A 46-year-old male enrollee requested authorization and coverage of gastric bypass surgery for treatment of morbid obesity with multiple comorbidities.  The health plan denied the enrollees 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 surgery is medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for surgery to remove a nabothian cyst and endometrial polyp. Nabothian cysts have a distinct appearance and are a common finding on pelvic examination. The cysts vary in size and although most lesions are asymptomatic, some may cause vaginal discomfort. These lesions are unlikely to cause pelvic pain and typically do not require treatment. In limited clinical settings when treatment is indicated, first-line options include draining or ablation of the cyst. Based on current data, surgical removal of a nabothian cyst is not considered a first-line modality, and can cause scar tissue leading to dyspareunia or cervical stenosis. With regard to the patients endometrial polyp, there is a lack of evidence on imaging that this polyp is still present. Furthermore, polyps are typically associated with abnormal vaginal bleeding, which is not documented in this patients records. Given these findings, the requested surgery to remove a nabothian cyst and endometrial polyp 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 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.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting reimbursement for partial hospitalization program (PHP) services. Findings:  The physician reviewer found that the enrollee has diagnoses of depression, anxiety, and post-traumatic stress disorder. Prior to admission, she was attending intensive outpatient program (IOP) sessions and receiving Transcranial Magnetic Stimulation (TMS) therapy. She reported difficulty with sleep and night terrors. She has a history of eating disorder, in remission and self-cutting to stop panic attacks. She has a significant trauma history and four past suicide attempts. On admission to the PHP, goals included managing panic attacks and working through trauma that she experiences during her life. Per the mental health discharge summary, regarding her goals, the patient believes she succeeded in managing panic attacks, was able to process a significant trauma in her life and wants to live, which is a different view from when she first arrived in treatment. There is no evidence in the medical records of suicide risk assessment after initial evaluation, work on chronic suicidal ideations as one of the goals and/or possible change in a strategy with regard to addressing chronic suicidal ideations. In applying LOCUS level of care assessment tool, the patients composite score is 17, which correlates with high intensity, community-based services. Final Result: The reviewer determined that the requested services are 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: Upheld

Nature of Statutory Criteria/Case Summary:   An enrollee has requested bariatric surgery (Lap-Band surgery) for treatment of her medical condition status post gastric bypass surgery with weight regain, reflux, and intermittent vomiting.  The physician reviewer found that although this patient presents with morbid obesity and has documentation of diabetes, the patient already had a prior laparoscopic Roux-en-Y gastric bypass procedure. While the requested procedure laparoscopic adjustable gastric band is considered a primary treatment for morbid obesity, it is not supported for patients when utilized as a salvage operation to be placed over a prior gastrojejunal anastomosis. There is a lack of evidence to support that this practice is safe, effective or results in any durable long-term weight loss. All told, the requested repeat bariatric surgery (Lap-Band surgery) is not medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the requested surgery 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 surgery with sub-specialty certification in bariatric 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: Medical Necessity
Decision: Upheld

The patient is a 54-year-old female who is approximately 100 pounds over her ideal weight. Her comorbidities are mild. She has been approved for gastric bypass with duodenal switch. The patient is requesting authorization for an immediate laparoscopic duodenal switch procedure. The Health Plan has denied authorization for the requested technique and timeframe citing a lack of medically necessity.The Health Plans denial should be upheld. There is no situation in which bariatric surgery needs to be performed on an emergent basis. Furthermore, there has been extensive literature demonstrating morbidity and mortality rates are excellent with the open duodenal switch procedure. Moreover, long-term results of the laparoscopic procedure are similar to the open procedure. Thus, as both the open and laparoscopic approaches are appropriate for the bariatric patient, it is not medically necessary for the patient to have the duodenal switch procedure performed laparoscopically.Based upon the information set forth above, I have determined the requested technique and timeframe are 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 reimbursement for the gene panel testing performed. Findings:  The physician reviewer found that the patient had a stroke at the age of 18 and a strong family history of early strokes. While the patients physical examination was unremarkable for Marfan, classic Ehlers-Danlos or Shprintzen syndromes, up to 20% of individuals with thoracic aortic aneurysm and dissection (TAAD) do not have classic features of these conditions. Furthermore, approximately 30% of families with heritable thoracic aortic disease (HTAD), a familial version of TAAD, who do not have a clinical diagnosis of Marfan syndrome or another syndrome possess a causative pathogenic variant in one of the known HTAD-related genes. These genes are part of the Marfan/TAAD sequencing panel. A gene specific diagnosis will inform the patient of recurrence risk and it will also change the management strategy for the patient.  Final Result: The reviewers determined that the testing 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: the reviewers are board certified in pediatrics and clinical genetics 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

The patient is a six-year-old male with a history of delayed fine motor skills. No other developmental delays are documented in the submitted records. The patient has been receiving occupational therapy since December 2004. The Health Plan authorized a portion of the therapy but has denied coverage for occupational therapy the patient received from February 2005 through July 2005 (except for dates of service from March 2005). At issue is whether the occupational therapy at issue was medically necessary.Based upon the clinical evidence provided, the patient does not have a defined illness, injury or congenital anomaly requiring occupational therapy. Additionally, in reviewing the therapy notes the first goal is an educationally based goal. The second goal is a sensory based objective with no measurable goal. The third goal is age appropriate, but the patient has not shown significant progress over the six months of therapy based on the daily progress reports provided. Furthermore, there are no follow-up progress reports documenting gains. All told, I have determined the services at issue were 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 Monovisc injection to the right knee for treatment of the enrollees knee pain. Findings: The physician reviewer found there is sufficient support for the requested services in this clinical setting. This patient presents with chronic right knee pain with associated stiffness, swelling and weakness. Functional limitations were documented with stairs and prolonged sitting. Clinical examination findings were consistent with the diagnosis of medial compartment osteoarthritis. He has not obtained significant symptom relief with prior conservative treatment, including medications, activity modification, and physical therapy. The records noted that prior viscosupplementation injections had provided significant sustained relief. It was also noted that he was attempting to delay knee replacement surgery given his young age. The peer-reviewed literature supports the use of viscosupplementation injections for the treatment of pain in patients with osteoarthritis of the knee. Repeat viscosupplementation injections have been found to be safe and effective and allow for delay of knee replacement surgery. Therefore, the requested Monovisc injection to the right knee is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in 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: Overturned

A 27-year-old male enrollee requested measurement of serum concentration of infliximab (IFX) and antibodies to infliximab (ATI) performed for medical treatment of the enrollees inflammatory bowel disease.  Findings:  Two physician reviewers found that in this case, the patient has inflammatory bowel disease, specifically Crohns disease. Due to the multitude of management options, it is important for the treating provider to have a roadmap of the nature of the patients clinical course. Measurement of serum concentration of IFX and ATI provides this roadmap and is the standard of care in treating Crohns disease. Based on its utility in managing the patients Crohns disease, the services at issue was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested treatment in a comprehensive cancer treatment center for treatment of her medical condition.   Findings: The physician reviewer found that the patient presents with an aggressive and rare cancer and was appropriately evaluated and treated at a large cancer center that has extensive experience in interdisciplinary care. Special cancer centers with such experience are designated as such by the National Cancer Institute (NCI) in a highly competitive peer-reviewed process for treatment of patients with aggressive disease. All told, the records support the requested treatment in a comprehensive cancer treatment center as medically necessary in this patients case.  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 medical oncology and hematology 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:  An enrollee has requested authorization and coverage for Otezla.The U.S. Food and Drug Administration (FDA) approved Otezla in 2014. Otezla (apremilast) is recommended for the treatment of moderate-to-severe psoriasis in adults. It receives an 'A' grade from the joint National Psoriasis/American Academy of Dermatology guidelines for its safety and efficacy and is recommended as first-line treatment of chronic plaque psoriasis. In this case, the patient has severe psoriasis with a BSA of 10%. The patient has tried and failed other conservative therapies. Further, according to the medical literature, Otezla has been demonstrated to be safe and efficacious for the treatment of psoriasis. Thus, Otezla is medically necessary for the treatment of the patients medical condition.Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in dermatology 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 9-year-old male enrollee has requested for a mental health partial hospitalization program for treatment of the enrollees major depressive disorder. Findings:  The physician reviewer found that The record reflects marked impulsivity, and the note indicates this patient recently exhibited aggressive and dangerous behavior toward his sibling.  Partial hospitalization allows for close monitoring of medication while adjustments occur, and it also allows for intense interventions for impulsivity and aggression and abnormal involuntary movements by a multi-disciplinary team.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Hyalgan injections to both knees and prospective authorization and coverage for Hyalgan injections to both knees. There is sufficient support for the services at issue in this clinical setting. A study performed a systematic review of overlapping meta-analyses comparing viscosupplementation with other nonoperative treatment modalities for knee osteoarthritis. The authors noted that intra-articular hyaluronic acid is a viable option for knee osteoarthritis. Its use results in improvements in knee pain and function that can persist for up to 26 weeks. The study noted that viscosupplementation has a good safety profile, and its use should be considered in patients with knee osteoarthritis. Therefore, previous Hyalgan injections to both knees and future Hyalgan injections to both knees were and are medically necessary for the 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 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: Medical Necessity
Decision: Upheld

A 46-year-old female enrollee has requested an abdominoplasty and panniculectomy for the treatment of her excess skin. Findings:  The physician reviewer found that the patients condition does not meet the American Society of Plastic Surgeons criteria for third party coverage of skin resection following massive weight loss.  According to the ASPS Position Paper Treatment of Skin Redundancy Following Massive Weight Loss, skin resection is medically necessary if panniculitis or uncontrollable intertrigo is present.  The records do not document panniculitis or the failure of medically supervised conservative therapy to control this patients intertrigo. She also does not meet the 2007 Apollo managed care guidelines for a panniculectomy. According to these guidelines, a panniculectomy is medically necessary if the pannus hangs below the pubis and chronic intertrigo is present and remains refractory to conservative medical therapy for at least three to six months. The records do not document three to six months of physician supervised medical management for intertrigo.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested partial hospitalization program (PHP) for eating disorders treatment for treatment of the enrollees anorexia nervosa.  Findings:  The physician reviewer found that according to the American Psychiatric Association (APA) criteria, this patient is medically stable. Her weight is generally above 80% of her ideal body weight. She seems to have fair motivation and is generally cooperative, although still needs to have reinforcement at times to continue her treatment. She still needs some structure to continue her program, but is eating her meals. Although she requires some additional structure beyond self-control to prevent her from compulsive exercising, she does not require the intensity of PHP services. She does not purge and does have a supportive environment. According to the APA guidelines, she most closely meets criteria for treatment at the intensive outpatient program (IOP) level of care. All told, the PHP for eating disorders treatment services provided were not and are not medically necessary for treatment of this patients medical condition.Final Result: The reviewer determined that the services at issue were not and 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 psychiatry with sub-specialty 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

The parent of a 1-year, 10-month-old male enrollee has requested speech therapy for treatment of the enrollees speech delay. Findings:  The physician reviewer found that according to the study from Law and colleagues, approximately 6% of children have speech and language difficulties. With regard to treatment, the researchers concluded that their meta-analysis demonstrates that there is a positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulties. Similarly, Bernhardt and Major concluded that, Results suggest that early phonological and metaphonological intervention can promote normalization of speech development and normal acquisition of literacy skills for at least some children with a history of severe phonological impairment.  This patient presents with speech and language deficits, particularly in the area of language expression. His speech and language deficits negatively impact his ability to play and communicate effectively. Studies have shown that speech and language therapy can result in significant improvement in such children. All told, speech therapy is medically necessary for treatment of this patients receptive and expressive language delay.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for Norco, four pills per day. The submitted documentation supports the medical necessity of the requested medication regimen. Per the Centers for Disease Control guidelines, patients tapering opioids after taking them for years might require very slow opioid tapers as well as pauses in the taper to allow gradual accommodation to lower opioid dosages. In this case, the patient is being stepped down greater than 30% in a one-step process. There is no titration down with other hydrocodone dose combinations that are available. A gradual taper is often necessary and if not successful, alternate detoxification may be indicated. Alternative therapies should be implemented to replace the analgesia provided by the hydrocodone. In the interval, the requested Norco, four pills per day, is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested medication regimen 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 anesthesiology with sub-specialty certification in pain 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: Medical Necessity
Decision: Upheld

The mother of a five-year-old male enrollee requested authorization and coverage of either Diflucan or Lamisil for treatment of the enrollees medical condition. The Health Plan  denied the request indicating that the requested medications are not medically necessary for treatment of the enrollees dysfunctional immune system.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that neither of the requested medications is medically necessary.