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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for intensive outpatient program services. The Health Plan has denied this request indicating that the services at issue were not and are not medically necessary for treatment of the enrollees behavioral health condition.Findings:  The documentation provided does not support the medical necessity for the services at issue in this clinical setting. There were no significant post-acute withdrawal symptoms and the patient denied same. The patient reported that his main complaint was sleep disruption. He denied cravings except for cannabis. The patient was not a danger to himself or to others. There were no emotional, behavioral, cognitive, or impulsive symptoms that would warrant IOP level of care. There was no evidence of a high degree of aggression, agitation, depression, mania, hallucinations, or any other significant symptom that would interfere with this patients care at a lower level. The patient was medically stable and psychiatrically stable during the dates in question. The patients medication regimen did not require close monitoring at IOP level of care.  There were no new problems that had arisen. Additionally, the records reflect that this patient demonstrated a lack of motivation and noncompliance throughout his treatment, as he did not fully participate in programs being offered. The patients partner was supportive, and the patient could have availed of psychotherapy, substance abuse counseling, and other forms of support and recovery if the patient did not choose to participate in a 12 step program. The patient required treatment and counseling. However, the patient could have received treatment on an outpatient basis. For these reasons, IOP level of care was not and is not medically necessary.Final Result: The reviewer determined 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 addiction psychiatry and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the oxygen concentrator, oxygen supplies and portable gaseous oxygen system provided for treatment of the enrollees chronic obstructive pulmonary disease (COPD). Findings:  The physician reviewer found that the Centers for Medicare and Medicaid Services (CMS) coverage requirement for home oxygen and portable oxygen requires an oxygen saturation of room air of 88% or lower. In this case, when the patient is at rest the oxygen saturation and the ABG document that the patient does not meet the criteria for oxygen. However, the records show that once the patient ambulates the oxygen saturation on room air decreases to 83%  and 80%. In this clinical setting, the patient meets criteria for the home oxygen concentrator and the portable oxygen system when she ambulates and/or exerts herself. Final Result: The reviewer determined that the services at issue were 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 internal medicine with sub-specialty certification in pulmonary disease 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 patient has requested authorization and coverage for evaluation for bioidentical hormone therapy. Findings:  The physician reviewer found that this patient presents with post-menopausal symptoms. The patient reported that she has been treated with bioidentical hormone for more than 10 years. Bioidentical hormones refer to custom-compounded, multi-hormone regimens that are dose-adjusted based upon serial hormone monitoring. The American College of Obstetricians and Gynecologists (ACOG) have advised against the use of custom-compounded hormones due to the lack of stringent quality controls regarding purity and dosing of these regimens. Due to the lack of U.S. Food and Drug Administration (FDA) supervision, these hormones are not recommended for routine use in the treatment of patients with post-menopausal symptoms. All told, the requested evaluation for bioidentical hormone therapy is not medically necessary for this patient. Final Result: The reviewer determined that the requested services are not medically necessary for evaluation 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the cardiac computed tomography (CT) for calcium scoring.Findings:  Two physician reviewers found that coronary calcium scoring is performed for screening purposes and indicates presence of CAD or coronary atherosclerotic plaque. Guidelines from the American College of Cardiology (ACC) have listed coronary calcium scoring as Class IIb (may be used) rather than a Class I recommendation (should be used) for use in preventive management. This recommendation suggests the testing may be useful if uncertainty remains after standard risk assessment. Overall, the current ACC guidelines recommend use of the pooled risk score to decide upon statin treatment in patients with elevated cholesterol. Also recommended are standard risk factors and standard lipid panels to decide upon preventive management. Final Result: Two reviewers determined that the testing at issue was 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: Medical Necessity
Decision: Upheld

A 49-year-old female enrollee has requested annual screening breast MRI for evaluation of potential breast disorder.  Findings:  The physician reviewer found that the utility of breast MRI for screening purposes is limited to those patients with known BRCA mutations. This patient has no history of breast cancer, no first line relative with a history of breast cancer and no known or reasonably presumed BRCA mutation. Breast MRI has not yet been proven to be more advantageous than standard imaging (mammography and breast ultrasound) in patients with dense breast tissue only.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for the LINX reflux management system for treatment of his gastroesophageal reflux disease (GERD). Findings:  Three physician reviewers found that this patient reportedly has GERD but corroborative pH recording results were not provided to support the diagnosis of symptomatic acid reflux. The available records support that he has benefited to a significant degree from acid suppression treatment, and as such cannot be considered medically refractory to acid blocker drugs. Further, the patients EGD described an unremarkable esophagus. Final Result: The reviewers determined that the requested procedure 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: Reviewers 1, 2, and 3 are board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested digital breast tomosynthesis for evaluation of her medical condition.  Findings:  Two physician reviewers found that the current medical evidence supports the services at issue in this clinical setting. Breast tomosynthesis provides advantages to radiologists interpreting mammograms.  This method often allows the reader to separate dense glandular elements from underlying mass/architectural distortion, resulting in a decrease in biopsies and callbacks and increase in detection of small cancers.  Thus, the addition of breast tomosynthesis to the usual two-dimensional protocol was likely of greater benefit to the patient than had her examination been done with two-dimensional imaging alone. Final Result: Two 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: All three reviewers are board certified in diagnostic radiology and are actively practicing. All three 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 continued lumbar epidural steroid injections for treatment of the patients pain management.  Findings:  The physician reviewer found that the peer-reviewed medical literature, epidural steroid injections may be appropriate for patients with radicular pain. However in this case, there is no current radicular pain complaints noted and epidurals are not recommended for non-radicular pain as a first-line treatment. Further, while the patient has been treated with physical therapy in the past, there is no documentation of recent physical therapy and home exercise program to address the patients current complaints. The literature does support and state that a home exercise program after physical therapy independent of an epidural can provide a patient with lasting results. Also, standard of care in this setting suggests another type of procedure may be more beneficial in this situation since the patient obtained 50% relief from one medial branch block at L2-5 and 50% relief from a sacroiliac joint injection (Derby, et al; Falco, et al). Finally, other medications have yet to be tried or optimized for his pain. For these reasons, the requested continued lumbar epidural steroid injections 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 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: 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: Two physician reviewers found that 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. In this case, the patient has heterogeneously dense breasts. While one could make the argument that her mammogram has not changed since the last study, 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. Therefore, the digital breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: Two 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: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for a laminotomy procedure. The submitted documentation supports the medical necessity of the services in issue. Studies show that conventional spinal decompression surgeries continue to be reliable treatments for symptomatic lumbar stenosis that is refractory to conservative management. In this case, the laminotomy performed at L5-S1 was made necessary by the presence of nerve root compression that required a decompressive procedure for adequate visualization and decompression of the nerve roots. In addition, there was a synovial cyst present at that level which needed exposure for an adequate resection. As such, the laminotomy at L5-S1 was reasonable, appropriate, and medically necessary. Accordingly, the laminotomy procedure was medically necessary for treatment of the enrollees medical condition.Final Result: The reviewer determined that the services in issue were 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: Overturned

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for the residential treatment center services provided from 10/28/17 through 1/26/18. The Health Plan has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavioral health conditions.  The submitted documentation supports the medical necessity of the requested residential treatment center services provided from 10/28/17 through 1/26/18. The records provided for review document that this patient required a safe and stable living environment in order to develop his recovery skills to prepare him to step down in treatment without high risk of relapse. Given this patients heavy substance abuse, history of withdrawal seizures, bipolar disorder and traumatic loss, he remained at high risk for relapse and harm to self throughout this admission. Thus, the residential treatment center services were in accordance with generally accepted standards of medical practice and clinically appropriate for the patients illness.Final Result: The reviewer determined that the requested the residential treatment center services provided from 10/27/17 through 1/26/18 were medically necessary for treatment of this patients behavioral health issues.  Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in psychiatry and 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 authorization and coverage for Acessa procedure. The records indicate that this patient has a history of pain and menstrual bleeding attributed to her fibroid uterus. The patient has requested treatment with the Acessa procedure. Studies support the safety and efficacy of the Acessa procedure for patients who meet specific clinical criteria. This patients uterus has several fibroids that are less than 3 cm and her fibroids are intramural, which fall within the guidelines. However, there is a lack of data that reduction of this patients fibroids, most of which measure less than 2 cm, will result in adequate symptomatic improvement. Moreover, the records suggest that the patient has adenomyosis, which would not be improved with the Acessa procedure. In this clinical setting, the standard of care remains hysterectomy or myomectomy. Therefore, the requested Acessa procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Findings:  Two of the three physician reviewers found the requested Acessa procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewers 1, 2, and 3 are board certified in obstetrics and gynecology 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 reimbursement for the digital breast tomosynthesis for evaluation of the enrollees risk for breast cancer. Findings:  Two physician reviewers found that 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, by separating the various layers of breast tissue, one can better detect abnormalities. This patient has breasts that have been described as being dense. It is specifically this type of patient with 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. Thus, in this clinical setting, the use of the digital breast tomosynthesis performed was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: The 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 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: Overturned

Nature of Statutory Criteria/Case Summary: The patients parent has requested reimbursement for a psychoeducational assessment. The records provided for review document that this patient sustained a head injury at six years of age due to a fall. The patient required inpatient psychiatric treatment for severe mood disorder with suicidal ideation with intent and plan. She has been evaluated and treated by two psychiatrists, and has completed at least three different medication trials without substantial improvement in her symptoms. She has also participated in occupational and speech therapy services for conditions consistent with neurological issues. She underwent a psychoeducational assessment for her persistent symptoms. In the medical literature, Pritchard and colleagues noted that untreated children with ADHD [attention-deficit/hyperactivity disorder], and those who have untreated comorbidities, are at greater risk for poor outcomes in social, academic, vocational, and practical settings. The authors reported that the current data supports the utility of neuropsychological assessments in this clinical setting to provide information that can potentially reduce risks for poor outcomes and improve quality of life among children with ADHD. Given this support, the psychoeducational assessment was medically necessary for this patient.  Final Result: The reviewer determined that the services at issue were 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 psychiatry with subspecialty certification in child and adolescent psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A forty-three year-old male with bilateral retinitis pigmentosa is requesting coverage of a referral to an eye institute.Reviewers Findings:  The reviewing physician found that the requested referral is not medically necessary for the patients condition.   The Health Plan denial was upheld.