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

A 38-year-old female enrollee requested authorization and coverage of an out-of-network laparoscopic duodenal switch bariatric surgery for the treatment of morbid obesity.  The health plan denied the enrollees request indicating that the requested treatment is experimental.Three physician reviewers performed an experimental/investigational Independent Medical Review.  Each of the three physician reviewers concluded that an out-of-network laparoscopic duodenal switch bariatric surgery is not likely to be more beneficial for treatment of the enrollees morbid obesity than any available standard therapy.  Because all three physician reviewers concluded that the requested treatment is not likely to be more beneficial for treatment of the enrollees medical condition than any available standard therapy, the review organization upheld the health plans denial.
Appeal type: Medical Necessity
Decision: Overturned

The parent of an 11-year-old male enrollee has requested 18 hours per week of applied behavioral analysis (ABA) services and 8 hours per month of ABA supervision for treatment of the enrollees medical condition. Findings:  The physician reviewer found that the medical literature supports the use of ABA therapy in the treatment of children with autism. ABA therapy has been documented in multiple studies to significantly improve motor, verbal, and social interactive skills in autistic children. While continued ABA therapy is medically necessary for this patient, the requested frequency of therapy is excessive in this clinical setting. As the patient has received more than 6 years of ABA therapy without significant response, the potential therapeutic effect of ABA therapy is limited. However, continuation of ABA treatment in an attempt to modify one or two behaviors such as elopement and refusals can be effective for the older child (Reichow, et al). Therefore, 5 hours of ABA therapy per week and 2 hours of supervision per month was and is medically appropriate and necessary. Based on the medical literature cited above and the documentation submitted for review, a portion of the services at issue were and are medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a two-year-old female enrollee has requested acute inpatient stay and bilirubin light treatment for the treatment of the enrollees jaundice. Findings:  The physician reviewer found that in 2004, the American Academy of Pediatrics published guidelines for management of hyperbilirubinemia in newborn infants born at more than 35 weeks gestation. Despite these guidelines, kernicterus has still occurred. Further guidelines and clarifications were recently published in 2009 in an effort to prevent the sequelae of severe hyperbilirubinemia. A number of risk factors for severe hyperbilirubinemia have been identified including pre-discharge transcutaneous or serum bilirubin measurement in the high-risk or high-intermediate-risk zone; lower gestational age; exclusive breastfeeding (particularly if weight loss is excessive or nursing is poor); jaundice observed within the first 24 hours; isoimmune or other hemolytic disease; previous sibling with jaundice; cephalohematoma or significant bruising; East Asian ethnicity. In a nomogram for designation of risk in term or near-term infants, a bilirubin of approximately 17.5 mg/dL at 96 hours of life would place the infant in the high-risk zone. In a second nomogram representing guidelines for phototherapy, an infant at medium risk for severe hyperbilirubinemia (term plus risk factors or near-term without risk factors) at 96 hours of life with a bilirubin level of 17 mg/dL or greater would merit phototherapy.Although the exact hours of life for the bilirubin levels obtained are not available for this patient, looking at the nomogram with an approximation of age places this infant in the high-risk zone at discharge at 24 hours, in the high-intermediate zone at 48 hours, and at the junction of the high-intermediate and high-risk zones at 96 hours. Her bilirubin level at the time of discharge is considered a risk factor, thus his bilirubin level at 96 hours of life justified hospital admission for phototherapy.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for Substance abuse partial hospitalization program (PHP) level of care services. Findings:  The physician reviewer found that  The patient has requested reimbursement for Substance abuse partial hospitalization program (PHP) level of care services. Per the American Society of Addiction Medicine (ASAM) criteria, this patient did not meet Level 2.5 criteria for PHP services. ASAM criteria focuses on six dimensions to determine the appropriate level of care, which includes: (1) intoxication and withdrawal potential; (2) biomedical conditions; (3) emotional, behavioral and cognitive conditions; (4) readiness to change; (5) relapse, continued use, or continued problem potential; and (6) recovery environment. For dimension 1, the patient had no signs or symptoms of withdrawal and his withdrawal needs could be safely met in a Level 2.5 setting. For dimension 2, the patient had a low testosterone level. The patients biomedical problems were stable and did not interfere with treatment. For dimension 3, the records do not document any psychiatric symptoms. For dimension 4, the patient admitted himself voluntarily at the encouragement of his wife and friends. He was motivated to complete the program. He did not appear to have problems with impulse control or to have unrealistic expectations that his alcohol problem will resolve quickly or with little effort. The records do not document failures at a prior level of care. For dimension 5, the patient reportedly relapsed after an 18-year history of sobriety. He was stepped down from a higher level of care before being admitted to the PHP. The patient did not lack awareness of relapse triggers, demonstrate difficulty in coping or postponing immediate gratification, or to be ambivalent towards treatment. For dimension 6, the patient lives with his wife and he enjoys his job. His wife was supportive of his treatment goals. There is a lack of documentation to suggest that a return to his living environment would make his recovery unlikely. Given these findings, the patient did not meet the six ASAM dimensions for PHP level of care services. Accordingly, the substance abuse PHP level of care services were not medically necessary for treatment of this patient.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 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: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for orthodontic treatment. The submitted documentation supports that the requested services are dentally necessary. The Handicapping Labio-Lingual Deviation (HLD) Index is one of four commonly used American and European orthodontic treatment need indices. These indices were devised to minimize the subjectivity associated with the diagnosis, referral and complexity assessment of malocclusion. The HLD Index, as with other indices, has a score component to determine orthodontic need as well as conditions that automatically qualify for dental necessity. One automatic qualifier is an overjet greater than 9mm. When using the HLD Index, if one of the automatic qualifiers is present, the examiner is to stop scoring. In this case, the submitted records show that an overjet of 11mm is present, which automatically qualifies treatment as dentally necessary. The records also show a retrognathic mandible with the lower anterior teeth positioned palatally to the upper incisors, which would be at risk for impinging on the palatal tissue. The orthodontic narrative describes the bite as presenting with lower incisors contacting the upper palatal tissue, which would be an automatic qualifier for dental necessity as well, but photographs neither confirm nor refute this. With one condition of excessive overjet confirmed as present, and a second qualifier of occlusion into the palatal tissues described, the submitted documentation supports that the requested services are dentally necessary. Accordingly, the requested orthodontic treatment is dentally necessary.Final Result: The reviewer determined that the requested services are dentally necessary for treatment of the patients dental condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in general dentistry 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 radiofrequency ablation of the right greater saphenous vein, varicose vein microphlebectomy. Obi and colleagues noted that in a study of 1,406 patients with varicose veins, endovenous treatment of axial reflux was the preferred treatment in 89.1%, divided largely between radiofrequency ablation at 55.2%, and endovenous laser ablation at 33.9%. In this case, the submitted records note the presence of pedal pulses and severe reflux in the vein to be treated, along with suitable diameters. Given that the records note that the patients symptoms are of a severity to limit daily activities despite efforts at conservative treatment, the requested service is medically indicated. Therefore, radiofrequency ablation of the right greater saphenous vein, varicose vein microphlebectomy, 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 vascular 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: The patient has requested reimbursement for a Monovisc injection (CPT J7327) of the left knee provided.Findings:  The physician reviewer found that although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. The current evidence is limited, and guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate that the evidence is not conclusive. In light of the foregoing, viscosupplementation can only be recommended in individuals with a history of lasting benefit from prior injections, and in carefully selected cases where everything else has been tried, and the options are limited. In this case, the patient has tried and failed arthroscopic surgery, corticosteroid injection, and other conservative treatments, with the alternative being a total knee arthroplasty. Given the patients limited options and based on the current medical literature, the service at issue was medically indicated. Therefore, the Monovisc injection (CPT J7327) of the left knee was medically necessary for the treatment of this patient.Final Result: The reviewer determined that the service 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 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: The patient has requested authorization and coverage for Synvisc One injection in both knees. Findings: Per the medical literature, although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. The current evidence is limited, and guidelines indicate that the evidence is not conclusive. In light of the foregoing, viscosupplementation can only be recommended in individuals with a history of lasting benefit from prior injections, and in carefully selected cases where everything else has been tried, and the options are limited. In this case, the patient has a history of relief from prior injections in 2019. The patient has tried and failed other conservative treatments, with the alternative being a total knee arthroplasty. Given the patients limited options and based on the current medical literature, the requested services are medically indicated. Therefore, Synvisc One injection in both knees are 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: Medical Necessity
Decision: Overturned

The parent of an 8-year-old female enrollee has requested  coverage for individual Applied Behavioral Analysis (ABA) therapy for treatment of the enrollees autism. Findings:  The physician reviewer found that ABA has been shown to be effective in treating behaviors associated with autism spectrum disorder. Treatments based on operant principles of learning are more effective for reducing maladaptive behaviors than alternative treatments. A 5-year randomized-controlled study involving 48 children with autism found significant improvements in IQ, adaptive behaviors and overall autism diagnosis using an Early Start Denver Model interaction based on developmental and applied behavior analysis principles and with at least 25 hours of intervention services weekly (Dawson, et al.).  Another article reviewed 34 studies of early intervention in autism and concluded that studies of Lovaas-based approaches and early intensive behavioral intervention variants and the Early Start Denver Model resulted in some improvement in cognitive performance, language skills, and adaptive behavior skills (Warren, et al.). A recent retrospective study compared a group of school-aged children who had been diagnosed with an autism spectrum disorder (ASD) when they were toddlers and who currently have optimal outcome to typically developing peers and peers with high-functioning autism spectrum disorder.  The authors noted that 62% of the children in the optimal outcome group received intensive behavioral therapy at a frequency of greater than 20 hours per week, whereas only 13% of the high-functioning group received this level of intervention (Kelley, et al.). Treatment intensity may play an important role and ABA therapy must be implemented at a sufficient intensity of between 30 and 40 hours per week in order to provide optimal outcomes (Kelley, et al. and Granpeesheh, et al.). Although substantial gains are made after one year of ABA therapy when compared to controls, further gains have been noted in subsequent years of therapy (Sallows, et al.). Many studies noted improvement of function in older children with autism spectrum disorders using intense ABA interventions (Granpeesheh, et al.). The goals for older children often are to identify and remediate particular deficits, such as self-injurious behavior and elopement with this patient. Therefore, intensive ABA therapy remains medically necessary for treatment of this patients autism. The proposed treatment plan of 35 hours per week of ABA therapy, 12 hours per month of supervision and 1.5 hours per month of clinical meetings is appropriate. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

A 61-year-old male enrollee has requested for Botox injections for treatment of his myofascial pain.   Findings:  The physician reviewer found that Botox has been proven to be useful in multiple conditions or pain disorders resulting from muscle spasms. Hence, the use of Botox therapy to relax muscle spasms in the TMJ area would decrease the pain and discomfort that he suffers from. In addition, the article cited above supports the use of Botox therapy to treat headaches related to temporomandibular dysfunction.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/ Case Summary: This patient is being seen for chronic pain in the upper, mid and lower back, pelvis, and lower extremity. The patient rates the pain 7-8/10 on a 1-10 scale, and experiences difficulties with the activities of daily living due to the pain. The patient has tried ibuprofen, meloxicam, naproxen, gabapentin, various opioids, Cymbalta, lumbar epidural injection and physical therapy. The patients current medications are Norco and baclofen. The provider is requesting lidocaine patches. At issue is whether the lidocaine patch is medically necessary to treat the patients medical condition. Researchers studied the effectiveness of the 5% lidocaine patch as compared with a placebo (a patch with no drug in it) in chronic back pain (CBP) patients in a randomized double-blind study. Overall, the effects of a lidocaine patch on CBP pain could not be distinguished from that of placebo (no drug). Therefore, the lidocaine patch is not medically necessary for this patient.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 anesthesiology and pain management and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for cell-free fetal DNA based prenatal testing for fetal sex chromosome aneuploidies and microdeletion syndromes for evaluation of the enrollee, who presented for fetal DNA testing. Findings: Two of the three physician reviewers found that this patient underwent noninvasive cell-free fetal DNA testing for aneuploidy including optional testing for sex chromosome anomalies and microdeletion syndromes at 12 weeks gestation. There is no reported family history of sex chromosome abnormalities, x-linked disorders or other genetic disorders. The patient requested reimbursement for cell-free fetal DNA based prenatal testing for fetal sex chromosome aneuploidies and microdeletion syndromes. The Health Plan denied reimbursement indicating that the services at issue were investigational for the evaluation of this patient. The American College of Obstetricians and Gynecologists and the Society for MaternalFetal Medicine recommends cell-free DNA testing as a screening option for women at increased risk of fetal aneuploidy. This population was defined as women 35 years or older, fetuses with ultrasonographic findings indicative of an increased risk of aneuploidy, women with a history of trisomy-affected offspring, a parent carrying a balanced Robertsonian translocation with an increased risk of trisomy 13 or trisomy 21, and women with positive first-trimester or second-trimester screening test results. There are three parts to this test, aneuploidy testing for chromosomes 13, 18 and 21, testing for sex chromosome abnormalities, and testing for microdeletions. For the patient's age, the the aneuploidy risk for this patient in this pregnancy warrants cell-free DNA testing for aneuploidy. However, the superior efficacy of the tests for sex chromosome abnormalities and microdeletion syndromes are not supported in the medical literature. Final Result: The reviewers determined that the services 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: 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: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:   An enrollee has requested medical treatment for his medical condition. Findings:  The physician reviewer found that the medical treatment at issue was medically necessary for treatment of the patients medical condition. Patients who have had a relatively prolonged period of disease control following their initial chemoradiotherapy and whose overall condition is good may be candidates for retreatment with a platinum-based combination. In this case, the patient received weekly chemotherapy with cisplatin, docetaxel, and cetuximab and radiation therapy. This treatment was medically necessary and is the standard regimen for non-pharyngeal head and neck cancer with recurrent disease according to the National Comprehensive Cancer Network (NCCN) guidelines. In addition, patients with head and neck cancer with one or a limited number of distant metastases at presentation or relapse may benefit from aggressive treatment that includes eradication of all known sites of disease. Radiation to the patients liver metastases would be considered for curative intent given his limited metastatic site of disease. All told, the medical treatment at issue was medically necessary for treatment of the patients medical condition.  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 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.