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

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement for residential mental health and substance abuse treatment services provided for treatment of the enrollees behavioral health conditions. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  This patient was very cooperative in treatment. On numerous occasions, she was noted to be helpful towards her peers and in a joyful mood.  The records indicate that the patient was cooperative with staff, and her activities of daily living appeared intact. The medical records do not support active suicidal ideation or psychosis at the time the patient was admitted to the residential treatment center or during the disputed period. The records indicate the patient was open to receiving therapy to aid with her behavioral health issues. The records do not indicate that she had failed intensive outpatient services prior to her admission to the residential treatment center. There were no significant or severe behavioral problems noted during her stay. Based on the records, the patient did not need the restrictiveness of a residential psychiatric treatment facility in order to receive her care. The treatment goals listed could have been accomplished on an outpatient basis. Residential treatment is used for acute stabilization of psychiatric conditions. It is not evidenced-based for long-term type treatment. Outpatient treatment and least restrictive options are considered first lines of care.  There are benefits to in-home therapy due to the involvement with family as well as generalization of learned skills in a natural setting. 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 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 authorization and coverage for Intracept procedure (CPT 22899 and HCPCS C9752  intraosseous basivertebral nerve ablation).Findings:  The physician reviewer found that Intracept procedure involves radiofrequency ablation of the basivertebral nerve for the treatment of patients with chronic low back pain. The U.S. Food and Drug Administration (FDA) has approved the Intracept procedure for the following specific indications: 1. chronic low back pain of greater than six months duration; 2. failure to respond to other nonsurgical treatments for six months; and 3. magnetic resonance imaging (MRI)-demonstrated Modic changes in at least one vertebral endplate at one or more levels from L3 to S1. The SMART trial by Fischgrund and colleagues was a prospective, randomized, sham controlled, double-blinded trial. The authors reported that at 24- and 60-month follow-up, patients demonstrated continued significant improvement in primary outcome measures when compared to their pretreatment condition. Khalil and colleagues performed an open-label, randomized, controlled trial of the Intracept procedure versus standard conservative therapy. As noted by the authors, the study was terminated early due to significant improvements in all outcome measures with Intracept versus standard therapy. On review of the available documentation, this patient meets the requirements for the Intracept procedure on the basis of the chronicity of his symptoms, failure of numerous other therapies, and imaging evidence of Modic changes at L4-5 and L5-S1. The patient has no documented contraindications to the procedure, and he has attempted treatment with some conservative strategies. All told, the requested Intracept procedure (CPT 22899 and HCPCS C9752  intraosseous basivertebral nerve ablation) is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings: Three of the three physician reviewers found the requested Intracept procedure (CPT 22899 and HCPCS C9752  intraosseous basivertebral nerve ablation) is 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 likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewer 1 is board certified in neurological surgery and is actively practicing. Physician reviewer 2 is board certified in neurological surgery and is actively practicing. Physician reviewer 3 is board certified in neurological surgery 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

The parent of a five-month-old female enrollee has requested a cranial remolding orthosis for the treatment of the enrollees brachycephaly. Findings:  Three physician reviewers found that this patient has documented plagiocephaly with a CI of greater than 80%. The gold standard for treatment of brachycephaly and plagiocephaly with synostosis is cranial orthosis therapy. The studies by Graham, et al. and Teichgraeber demonstrate the benefit of orthosis therapy with brachycephaly. Although these studies showed there was not a complete resolution of the brachycephaly, there was significant improvement.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Prolaris genetic testing. The three current options for the management of localized prostate cancer include surgical prostatectomy, radiation therapy and similar techniques, and surveillance. A risk stratification analysis based on clinical and pathologic factors may predict a patients risk for progressive cancer and assist in making treatment recommendations. In this case, the records noted a diagnosis of malignant neoplasm of prostate and an elevated prostate-specific antigen (PSA) level of 3.97. A biopsy reported adenocarcinoma in the left lateral apex and the right apex and elements of Gleason 3+3 and 3+4 disease. In this clinical setting, the National Comprehensive Cancer Network (NCCN) recommends molecular-genetic testing, such as Prolaris genetic testing, as an aid in making therapeutic recommendations. Therefore, Prolaris genetic testing was likely to be more beneficial for the evaluation of the patients condition than any available standard therapy.Findings:  Three of the three physician reviewers found the Prolaris genetic testing was likely to be more beneficial for the evaluation of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the service 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: Physician reviewer 1 is board certified in internal medicine with sub-specialty certification in medical oncology and actively practicing. Physician reviewers 2 and 3 are board certified in internal medicine with sub-specialty certifications in medical oncology and hematology 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 patient has requested authorization and coverage for Synvisc One injection in both knees. Findings:  The physician reviewer found that there is good 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 study conducted a systematic review of overlapping meta-analyses comparing viscosupplementation with other non-operative treatment modalities for knee osteoarthritis. The study  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 in both knees are supported as medically necessary for treatment of this patients knee osteoarthritis. Final Result: The reviewer determined that the requested service is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The parent of an 11-year-old female enrollee has requested  for custom orthotics for treatment of the enrollees flat feet. Findings:  The physician reviewer found that it is a well accepted theory that pathomechanics of the foot can cause knee and low back pain. It is also well accepted and proven that orthotics can control abnormal motion of the foot.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for bilateral nerve decompression for treatment of the enrollees migraine headaches.Findings:  Three physician reviewers found that currently, nerve decompression has not been validated in the peer-reviewed medical literature as an effective treatment option in occipital neuralgia or migraine. The standard surgical procedure for refractory occipital neuralgia is C2 radiofrequency or rhizotomy. However, this patient has had minimal standard treatment for his migraines or occipital neuralgia. Thus, his condition cannot be considered refractory. Therapies such as gabapentin, topiramate, and beta blockers, or Botox have not been attempted for treatment of chronic migraine have not been utilized.  Final Result: Three reviewers determined that the requested service 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: Two physician reviewers are board certified in internal medicine with sub-specialty certification in neurology and are actively practicing.  One physician reviewer is board certified in internal medicine with sub-specialty certifications in neurology and pain medicine and is 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

A 41-year-old female enrollee has requested Imitrex (18 boxes per 90-day period) for treatment of her migraines.  Findings:  The physician reviewer found that the patients medical records suggest that she has chronic migraine, with a recent note documenting 16 severe headaches in a month. The American Academy of Neurology (AAN) guidelines based on well reviewed literature recommends prevention therapy with headaches of frequency more than four days per month that are disruptive, and acute abortive medications to reduce disability. The use of abortive medications more than an average of two to three days weekly can lead to medication overuse headache, and thus combined prevention treatment, and effective abortive use is advisable. Use of an average of 12 triptan doses per month (such as two doses per day, two days per week, for a total of 16 doses per month) is reasonable, but patient education in necessary to avoid overuse. Evaluation by a headache specialist, use of a headache diary, adjustment of preventives, efforts to facilitate weight loss, and consideration of re-treatment with Botox as per FDA approved dosing (155 units) are all indicated. In the interim, use of Imitrex at 18 boxes with 36 subcutaneous doses in 90 days is medically necessary, in conjunction with patient education.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the residential treatment center (RTC) services. Findings: The physician reviewer found that applying the Level of Care Utilization System (LOCUS) criteria, the RTC services were not medically necessary for treatment of this patients behavioral health issues. The patient presented with a low risk of harm (score 2) as the patient did not have any suicidal or homicidal ideation. In addition, the patient does not have a history of suicide attempts. The patient demonstrated moderate functional impairment (score 3) with a significant deterioration in his ability to fulfill responsibilities. The patient had significant co-morbidity (score 3) with ongoing substance use despite negative consequences. The patients recovery environment was moderately stressful (score 3) since the patient was living off his savings, had many relationships that have ended due to his substance use, and he had easy access to alcohol and drugs. The patient had limited support in the environment (score 3) but he demonstrated significant response to treatment and recovery (score 2) with effective prior treatments resulting 9.5 years without using substances prior to his relapse. The patient demonstrated limited engagement and recovery (score 3) since he was motivated to recover, but he wanted treatment to be done on his terms. He felt that the environment was too restrictive and left against medical advice. These results give the patient a composite score of 19, which is consistent with intensive outpatient program (IOP). Throughout the patients stay, the patient was a candidate for treatment in a less restrictive environment. The patient continued to require treatment for his substance use disorders, but this could have been accomplished in a less restrictive environment. Therefore, the RTC services were not medically necessary. 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 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 46-year-old female who underwent a panniculectomy in 2000. Postoperatively, the patient was noted to have fullness in both sides of the lower abdomen with reported tenderness. The patient was seen and evaluated by a plastic surgeon in January 2004 for similar complaints after a stated 40-pound weight loss. The surgeon offered several options at the time and suggested that the patient wait until she reached her plateau weight before pursuing surgery. She was re-evaluated in March 2004 with essentially the same findings. The patients plastic surgeon has recommended a skin-only abdominoplasty. The Health Plan has determined that the requested procedure is not medically necessary for treatment of the patients medical condition.The submitted evidence does not demonstrate that the proposed procedure is medically indicated. There is no evidence that the patient has tried and failed conservative management of intertrigo. Thus, there is insufficient documentation of functional impairment to warrant an abdominoplasty at this time. Therefore, I have determined that the requested procedure is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for 30 treatments (two hours per treatment) of hyperbaric oxygen therapy in a multi chamber provided by Ronald Gordon Medical Corporation. Kleban and Baynosa state, Hyperbaric oxygen (HBO2) therapy can serve as a useful adjunct in the salvage of compromised flaps and grafts. The literature demonstrates the benefit of adjunctive HBO2 therapy for multiple types of grafts and flaps with various etiologies of compromise. HBO2 therapy can enhance graft and flap survival by several methods, including decreasing the hypoxic insult, enhancing fibroblast function and collagen synthesis, stimulating angiogenesis and inhibiting ischemia-reperfusion injury. The expedient initiation of hyperbaric oxygen therapy as soon as flap or graft compromise is identified maximizes tissue viability and ultimately graft/flap salvage. Bassetto and colleagues note that hyperbaric oxygen therapy may be indicated for compromised flaps and grafts. While current medical literature documents the utility of hyperbaric oxygen therapy in compromised flaps/grafts, in this case, the patient began hyperbaric oxygen therapy two months after his fat grafting. The patient reported concerns over irregularities in contour and in breast shape, both of which are functions of surgical technique, rather than a consequence or symptom of a compromised fat graft at two months post procedure. While the patient reported chest tenderness, such tenderness in the area of extensive fat grafting is within the range of normally expected postoperative healing and is not a consequence or symptom of a compromised fat graft at two months post procedure. In this case, given that the records do not demonstrate clinical evidence of a compromised graft, the services at issue were not medically indicated. Therefore, 30 treatments (two hours per treatment) of hyperbaric oxygen therapy in a multi chamber provided by Ronald Gordon Medical Corporation were not medically necessary for the 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 plastic 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 64-year-old male enrollee requested authorization and coverage of gastric bypass with duodenal switch. The Health Plan denied the request indicating that the requested procedure is not medically necessary for the treatment of the enrollees morbid obesity.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested procedure is not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested Sovaldi and Daklinza for treatment of her hepatitis C virus genotype 2.  Findings: The physician reviewer found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. The guidelines only recommend one therapy for ribavirin-ineligible genotype 2 patients who have failed peg-interferon with ribavirin, which is Sovaldi and Daklinza. This recommendation is based on two clinical trials (Wyles, et al; Sulkowski, et al). Further, the AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment (Jezequel, et al). This patient is ineligible for alternatives containing interferon or ribavirin due to prior severe adverse reactions, and a pre-existing medical condition.   For these reasons, the requested treatment with Sovaldi and Daklinza is supported as medically necessary for the treatment of this patients hepatitis C infection.  Final Result: The reviewer determined that the requested medications are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Qualifications/Credentials: The physician reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology 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 her medical condition. Findings:  Three physician reviewers found that in the peer-reviewed medical literature, Skaane and colleagues found that the addition of three dimensional digital breast tomosynthesis to two dimensional full field digital mammography resulted in a significantly higher cancer detection rate and enabled the detection of more invasive cancers. Thus, although additional studies are needed to confirm these findings, there is adequate data to support the utility of three dimensional digital breast tomosynthesis in this clinical setting. For these reasons, breast tomosynthesis was likely to be more beneficial for evaluation of this patients medical condition than any available standard therapy. Final Result: Three 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: Overturned

The parents of a 5-year-old male enrollee requested authorization and coverage of speech therapy and occupational therapy for the treatment of autism.  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 requested therapy is medically necessary for treatment of the patients medical condition.