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

Nature of Statutory Criteria/Case Summary: The parent of an 11-month-old enrollee has requested developmental testing with interpretation for evaluation of the enrollees medical condition.  Findings: The physician reviewer found that according to De Kegel and colleagues, A congenital CMV [cCMV] infection is a risk factor for a delay in the early motor development. Follow-up will be necessary to gain insight into the exact cause of this motor delay and to define the predictive value of early motor assessment of cCMV infected children. Thus, congenital CMV has known implications on development and hearing. Children with congenital CMV require closer monitoring than other children on their development. The study by De Kegel and colleagues found that children with congenital CMV were more likely to have motor delays and require physical in the first 18 months of life and recommended monitoring development at 6, 12 and 18 months. Milewska-Bobula and colleagues found considerable developmental delays even in mildly symptomatic children with congenital CMV and recommended longer term close monitoring of development even into school age. Celikel and colleagues found that 48% of children with congenital CMV will have implications on their long-term development and recommended long-term follow-up. Thus, children with congenital CMV require a higher level of screening. In this case, the patient presents with congenital CMV and requires ongoing neurodevelopmental follow-up at a tertiary care provider. Based on the support in the peer-reviewed literature, the developmental testing with interpretation and report has been established as medically necessary for evaluation of the patients medical condition.Final Result: The reviewer determined that the testing at issue was medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in pediatrics with sub-specialty certification in developmental-behavioral pediatrics and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Synvisc One injection to the right knee. There is adequate evidence that intraarticular hyaluronic acid injections reduce pain and increase function in knee osteoarthritis, and the benefits are long-lasting as compared with intraarticular corticosteroids. A systematic review of overlapping meta-analyses comparing viscosupplementation with other non-operative treatment modalities for knee osteoarthritis. It was reported that the current highest level of evidence suggests that intraarticular hyaluronic acid is a viable option for patients with knee osteoarthritis which results in improvements in knee pain and function that can persist for up to 26 weeks. Viscosupplementation has a good safety profile, and its use should be considered in patients with knee osteoarthritis. All told, the requested Synvisc One injections to the right knee is supported as medically necessary for treatment of this patients knee osteoarthritis. 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: Upheld

The parent of a three-year-old male enrollee has requested hyperbaric oxygen therapy (HBO) for treatment of the enrollees autism.  Findings:  Three physician reviewers found that a review of the published literature indicates that HBO therapy is a controversial treatment for autism and speech delay and of questionable efficacy. There are no valid, controlled, double-blind, reproducible studies showing that HBO therapy results in measurable improvement. This treatment is not the standard of care for the management of autism and is clearly investigational at this time.
Appeal type: Medical Necessity
Decision: Upheld

A 23-year-old male enrollee has requested surgical repair of discoid meniscus for treatment of his knee pain. Findings:  The physician reviewer found the submitted documentation fails to demonstrate the medical necessity of the requested services.  In this patients case, the recommended conditioning physical therapy program and continued observation is medically appropriate for the management of the patients knee pain.  While MRI has revealed a discoid meniscus, it has not demonstrated any meniscal tears within the structure.  Discoid meniscus can be an incidental finding.  The medical literature documents that a discoid meniscus is more prone to tears but in the absence of MRI documentation of a tear and no more than small knee effusions, no documented instability, no flexion contracture and no specific meniscal signs, it is not likely to be beneficial for this patient to undergo a surgical exploration.  All told, the requested surgical repair of discoid meniscus is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Synvisc injections in both knees.An exhaustive review of the current medical literature pertaining to viscosupplementation reveals mixed results. Evidence from eight systematic reviews and six randomized controlled trials indicates that although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. Different studies have tried mixing hyaluronic acid with corticosteroids, platelet rich plasma, and other agents to make it more effective. 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, there is a history of excellent lasting benefit from prior injections. Furthermore, the options are limited. The submitted documentation shows that the patient is unable to use corticosteroid injections because of stated contraindications. Therefore, Synvisc injections in both knees are medically necessary for the treatment of the patients medical condition.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: Upheld

A 51-year-old female enrollee has requested transcranial magnetic stimulation (TMS) therapy for treatment of her major depressive disorder. Findings:  Three physician reviewers found that the submitted documentation does not demonstrate that comorbid factors which may have adversely impacted the patients response to treatment, such as substance abuse, Axis II issues or psychosocial stressors, have been adequately investigated and addressed. American Psychiatric Association guidelines indicate electroconvulsive therapy as the most effective treatment for depression.  The study by Eranti and colleagues supports this conclusion. There are insufficient data regarding the efficacy of this procedure to warrant its use in standard practice. While transcranial magnetic stimulation may be effective in treating depression, current research does not establish its superiority to other antidepressant treatment.  Thus, transcranial magnetic stimulation provided was not likely to have been more beneficial than other treatment options in this patients case.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: A minor represented has requested reimbursement and prospective authorization and coverage for intensive outpatient program (IOP) services. Findings:  The physician reviewer found that the progress notes do not reflect severe regular emotional outbursts or other issues that would warrant IOP level of care treatment. The progress notes indicate the patient was uncooperative in treatment. Admission records suggest the treatment goals are related to improvement of social relationships skills, reduction of anxiety, and improvement of family relationships. The patient reportedly shaved off parts of her hair, but the documentation does not indicate any other issues with aggression or behavior outbursts. The progress notes do not indicate that the patient was demonstrating any serious mood symptoms or psychosis. The progress notes do not reflect active suicidal ideation on the part of the patient. The progress notes indicate the patient has a history of self-harm behaviors. She was not experiencing self-harm during the IOP according to the progress notes. For these reasons, the IOP 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested breast tomosynthesis for evaluation of the enrollees risk for breast cancer. Findings: Three physician reviewers found that Tomosynthesis was approved by the U.S. Food and Drug Administration (FDA) for clinical use in 2011. Despite the lack of long-term studies proving an increased survival rate when tomosynthesis has been used as part of screening mammography, the American College of Radiology (ACR) urged the technique be removed from the investigational category in 2014 due to the advantages this new tomographic technique brings to radiologists interpreting mammograms. This technique often allows radiologists to separate dense glandular elements from underlying masses and architectural distortion resulting in a decrease in callbacks and increased detection of small cancers. Thus, the addition of tomosynthesis to the usual two dimensional protocol was likely of greater benefit to this patient than had her exam been done with two dimensional imaging alone. Accordingly, the breast tomosynthesis that was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: Three 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: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for neuropsychological testing for evaluation of the enrollees difficulties with attention regulation, managing her emotions and academic concerns. Findings: the physician reviewer found a study showing that there is a lack of evidence supporting neuropsychological testing as improving outcomes in diagnosing and treating patients with ADHD. Moreover, neuropsychological testing is not the standard of care in this clinical setting. The diagnosis of ADHD is typically made utilizing a standard psychiatric evaluation, parent surveys, teacher surveys, and other rating scales and screening tools. Final Result: The reviewer determined that the testing at issue was 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 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Humira (adalimumab).Humira is a TNF alpha blocking medication that was approved for the treatment of chronic plaque psoriasis in 2008 by the U.S. Food and Drug Administration. It is widely used and is safe and efficacious. Humira (adalimumab) is given a rating of A by the recently published National Psoriasis Foundation/American Academy of Dermatology guidelines for use as monotherapy. In the treatment of psoriasis, methotrexate was shown to have a four times greater risk of adverse events than Humira in the CHAMPION study. In this case, the patient has been diagnosed with chronic plaque psoriasis affecting his skin and genital area, and treatment with topical creams and UV therapy has not provided relief. The patient also has elevated liver enzymes and a fatty liver, which make methotrexate a poor choice as an initial treatment due to methotrexates risk of liver toxicity. Under these circumstances, Humira (adalimumab) is medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested medication is medically necessary for the 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 parents of a 6-year-old male enrollee requested authorization and coverage of twelve  speech therapy sessions for the treatment of moderate to severe somatic dysfunction of the cranium secondary to traumatic birth and delivery.  The Health Plan denied the enrollees request indicating that the requested treatment 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 services are  medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The patient has requested authorization and coverage for weekly or biweekly psychotherapy services and transcranial magnetic stimulation (TMS). Patients with treatment-resistant depression have failed to improve, despite multiple antidepressants and augmentation strategies. This patients records document the presence of treatment-resistant depression. She has failed adequate trials of standard medications used in the treatment of depression including Abilify, Seroquel, Zoloft, and Prozac, as well as others. The American Psychiatric Association (APA) guidelines for the treatment of depression support the use of TMS in the acute phase of treatment. Researchers provided data demonstrating that TMS was significantly more likely than sham treatment to produce remission in patients with treatment-resistant depression. Similarly, TMS has been shown to be safe and effective with minimal side effects. The available data support TMS as an effective treatment for use in treating this patients treatment-resistant major depressive disorder. Moreover, researchers noted that, psychotherapy is an integral part of patients treatment and should be considered for initial therapy for mild depression and as augmentation to an antidepressant for moderate or severe depression or for patients with adherence problems. Moreover, the authors noted that psychotherapy is effective for acute depression, particularly in combination with antidepressants, and can help in preventing depressive relapse and recurrence. Given the support in the medical literature and APA guidelines, the requested weekly psychotherapy services and TMS are medically necessary for 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 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 patient is a 46-year-old female with a body mass index (BMI) of 49. She has comorbid conditions of hypothyroidism and hypertension. She has requested authorization for bariatric surgery. She has not undergone a psychological evaluation to determine whether she is an appropriate candidate for weight loss surgery. The Health Plan has denied the patients request.With a BMI of 49 and comorbid conditions such as hypertension, 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 clinical evidence demonstrating that further weight loss is necessary for a successful surgery and there is no scientific evidence supporting this requirement. However, although medically the patient meets criteria for consideration of weight loss surgery, there is no evidence that the patient has undergone a psychological evaluation to determine whether she is an appropriate candidate for weight loss surgery. Such an evaluation is considered standard of care prior to authorizing weight loss surgery.Based upon the information set forth above, I have determined that the requested procedure is medically necessary for treatment of the patients medical condition depending upon the results of a psychological evaluation. Therefore, the Health Plans denial should be overturned. If the psychological evaluation indicates the patient is an appropriate candidate for weight loss surgery, the procedure should be authorized. If the psychological evaluation indicates the patient is not an appropriate candidate for weight loss surgery the procedure should not be authorized.
Appeal type: Medical Necessity
Decision: Upheld

The parents of a 15-year-old female enrollee requested authorization coverage for continued trigger point injections.  The health plan has denied this request indicating that the requested injections are not medically necessary for treatment of the enrollees back pain.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer upheld the health plans denial on the basis that the requested injections are not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for positron emission tomography (PET) scan (CPT code 78813). The submitted documentation fails to demonstrate the medical necessity of the requested services. Normal surveillance for tumor recurrence for patients after surgery/radiation therapy for prostate cancer includes serial serum prostate-specific antigen (PSA) levels and digital rectal examinations. Appropriate surveillance for recurrent thyroid cancer includes monitoring of serum thyroglobulin levels and neck ultrasound. According to the American College of Radiology appropriateness criteria, PET/CT is usually not appropriate for prostate cancer follow-up with clinical concern for recurrence. In the absence of rising PSA levels, the search for the presence of recurrent disease is usually not warranted, imaging or otherwise. The National Comprehensive Cancer Network recommends surveillance of thyroid cancer status post thyroidectomy by means of monitoring thyroglobulin levels, physical examination and periodic neck ultrasound. In the setting of rising thyroglobulin levels, further imaging is warranted. However, PET/CT is not indicated in routine post-treatment surveillance with normal thyroglobulin levels. In this case, the routine surveillance of this patients prostate and thyroid cancer has not yielded any increased suspicion for recurrence. Imaging examinations of the pelvis have been stable for over two years, therefore making the diagnosis of osseous metastases unlikely. Therefore, PET scan is not an appropriate examination in this case. Thus, the requested PET scan (CPT code 78813) is not medically necessary for the evaluation of this patient.Final Result: The reviewer determined that 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 diagnostic radiology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 46-year-old male enrollee has requested continued rehabilitation therapies and skilled nursing services for the treatment of the enrollee, who is status post pelvic fracture. Findings:  The physician reviewer found that the patient was not safe for discharge during the dates of service at issue, and he was progressing with physical therapy and occupational therapy. His needs were not custodial. The prevailing practice standard is to complete rehabilitation for patients transferred to a skilled nursing facility for rehabilitation. In this case, the patients skilled nursing facility-based rehabilitation was not complete as of the last authorized date of service and it would not have been reasonable to provide the patient with a lower level of care. The Health Plans assessment of the patients needs was not consistent with his clinical course in rehabilitation.