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

The patient is a 62-year-old male with a body mass index of 50. He has significant obesity related comorbidities. The patient is estimated to be a high operative risk (5%). The patient wishes to undergo gastric bypass with duodenal switch. The Health Plan has determined that the requested procedure is not medically indicated for treatment of the patients medical condition.With a body mass index (BMI) of 50 and significant comorbid conditions, the patient appears to be an appropriate candidate for weight loss surgery. Given the patients BMI and comorbidities duodenal switch would be the preferred weight loss procedure. However, given the significance of his comorbidities he is a high operative risk. As such, updated cardiac and nephrology evaluations are necessary to determine if surgery is a viable option for this patient. Therefore, I have determined that the requested procedure is not medically necessary for treatment of the patients medical condition at this time. The Health Plans denial should be upheld at this time. If the results of the cardiac and nephrology evaluations indicate the patient is a viable candidate for surgery, the requested procedure should be authorized. If the results of the cardiac and nephrology evaluations indicate the patient is not a viable candidate for surgery, the requested procedure should not be authorized.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The enrollee has requested reimbursement for the balloon sinus ostial dilation provided. Findings:  The physician reviewer found that according to the American Academy of Otolaryngology, Head and Neck Surgery (AAOHNS) chronic rhinosinusitis is defined as a persistent inflammatory disorder of the paranasal sinuses with symptoms of persistent facial pain, discolored nasal discharge, and symptoms that are refractory to appropriate medical management including antibiotics, nasal anti-inflammatory medications and decongestant therapy. Additionally, computed tomography (CT) scan imaging usually demonstrates extensive mucous membrane changes within the ethmoid, maxillary and other paranasal sinuses with blockage of the ostiomeatal complex. At present, functional endoscopic sinus surgical techniques for the management of recurrent acute and chronic rhinosinusitis which are refractory to medical management are still considered the surgical treatment of choice. Orlandi and colleagues noted that conservative approaches can provide short-term clinical outcomes comparable to traditional endoscopic sinus surgery in patients with limited disease. For patients with moderate-to-severe chronic rhinosinusitis, traditional endoscopic sinus surgery has the potential for improved long-term sinus ventilation and delivery of topical medications. All told, the balloon sinus ostial dilation provided was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: All three of the reviewers determined that the service at issue was 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 & 3 are  board certified in otolaryngology 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

The parent of a 15-year-old male enrollee has requested acute inpatient services for the treatment of the enrollees major depressive disorder. Findings:  The physician reviewer found that the medical documentation indicates that the patient remained at high risk for self harm behavior and was in need of the level of care provided. The services provided are consistent with the standards of care and practice guidelines established by the American Academy of Child and Adolescent Psychiatry.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 15-year-old male with attention deficit and obsessive-compulsive disorders who has idiopathic short stature. Work-up including MRI of the brain, IGF-1, IGFBP-3 and thyroid evaluation were unrevealing. The growth chart indicates a falling off in stature from 12 years of age despite relative increases in weight. When the patients endocrinologist initiated growth hormone (GH) therapy, the patient had a projected adult height as low as 52 despite his target height based upon his parents stature of 59.5. The notes supplied indicate that his twin sister was 54 tall at age 14 years. The growth response to GH has been reported to be good. The patients parent has requested reimbursement as well as prospective authorization for growth hormone therapy. The Health Plan has denied this request citing a lack of medical necessity for growth hormone treatment.The Food and Drug Administration has approved growth hormone for the treatment of idiopathic short stature as a medically indicated therapeutic intervention to promote growth velocity and final adult height. The patients presentation is consistent with idiopathic short stature. The submitted clinical information indicates the patient has had a significant growth response since GH therapy was initiated. As such, there is sufficient evidence supporting the medical necessity for the patients past and continued use of GH therapy.  Based upon the information set forth above, I have determined the therapy at issue was/is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a two-year-old female enrollee has requested speech therapy for treatment of the enrollees mild receptive language impairment, severe expressive language impairment and severe impairment in feeding skills. Findings:  The physician reviewer found that in this patients case, the requested speech therapy is medically indicated. As noted by Nelson and colleagues, speech and language development is considered by experts to be a useful indicator of a childs overall development and cognitive ability and is related to school success. Identification of children at risk for developmental delay or related problems may lead to intervention services and family assistance at a young age when chances for improvement are best. Law and colleagues noted that there is a positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulties. Bernhardt and Major concluded that early phonological and metaphonological intervention can promote normalization of speech development and normal acquisition of literacy skills for some children with a history of severe phonological impairment. This patient has severe expressive language delay and severe impairment in feeding, negatively impacting her ability to achieve age-appropriate functional skills and milestones. Studies have shown that speech and language therapy can result in significant improvement in speech and language development in such children. Additionally, it is another avenue from which to improve feeding skills. All told, the requested speech therapy is medically necessary for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Overturned

The parent of a 17-year-old female enrollee has requested genetic testing (CPT code 81382) to rule out celiac disease for evaluation of the enrollees abdominal pain.  Findings:  Three physician reviewers found that in this patients case, the requested testing is likely to be more effective than other methods of evaluation.  There is adequate support for the requested genetic testing to rule out celiac disease in this clinical setting.  As noted by Coburn and colleagues, human leukocyte antigen (HLA) genotyping is useful for the evaluation of patients on a self-treated gluten-free diet.  Vives-Pi and colleagues noted that genetic risk factors have been identified for celiac disease.  All told, the requested genetic testing to rule out celiac disease is likely to be of greater benefit than other options for evaluating this patient.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for MC6000Tilt (all in one commode chair, tub access slider system and in-home mobility chair). Findings:  The physician reviewer found that At issue is whether the requested MC6000Tilt (all in one commode chair, tub access slider system and in-home mobility chair) is medically necessary to treat the patients medical condition. The submitted documentation supports that the requested DME is medically necessary. The patient has a history of mid cervical spinal cord injury with chronic tetraplegia, neurogenic bladder, and neurogenic bowel. She has been dependent for her self-care such as bathing, toileting, and dressing. She has been living in the community with caregiver assistance, using durable medical equipment such as a commode-shower chair. Given her level of injury and impairments, the patient does require significant truncal and limb support for safely sitting on equipment such as commode and shower chairs. Features such as cushioning and tilt-in-space are required because activities such as bowel care and showering can take prolonged periods of time, putting the patient at risk for pressure injuries as well as discomfort. Given that the patient has very limited limb and truncal control and she is dependent for transfers, transfers out of a tub (particularly when wet after a shower) are challenging and can be unsafe without appropriate precautions, which include proper equipment. Under these circumstances, the requested custom shower-commode chair with features such as tilt-in-space and slide transfer ability is medically necessary for this patient to safely accomplish her basic activities of daily living. Other equipment such as a standard commode chair and standard shower chair without these features is insufficient to meet the patients bathing and toileting needs safely and efficiently in the community. Accordingly, the requested MC6000Tilt (all in one commode chair, tub access slider system and in-home mobility chair) is medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested durable medical equipment is medically necessary to treat the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in physical medicine and rehabilitation 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 63-year-old male enrollee has requested coverage for arthroscopic superior labrum anterior to posterior (SLAP) tear repair for treatment of his shoulder pain.  Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the requested procedure.  The surgical treatment of rotator cuff tears is generally accepted by orthopedic surgeons for patients whose symptoms are not relieved by adequate conservative measures, or for those whose tear is complete. There is evidence of efficacy on long-term study.   However, there remains much variation among surgeons as to the indications for surgery.  With regard to the question of a superior labrum anterior to posterior (SLAP) tear, the Milliman Care Guidelines do indicate the need for magnetic resonance arthrographic or other imaging confirmation of the presence of the SLAP tear.   In this case, there is no documentation of the presence of a SLAP tear on imaging. In addition, there is a lack of documentation of conservative management, other than the injections noted and pendulum exercises. All told, the requested arthroscopic superior labrum anterior to posterior (SLAP) tear repair is not medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

A 50-year-old female enrollee requested bronchial thermoplasty for medical treatment of her severe persistent asthma. Findings:  Three physician reviewers found that the studies performed to date demonstrate the benefit of bronchial thermoplasty for poorly controlled asthma. Patients who require and benefit from it are poorly controlled, severe persistent asthmatics who have failed all manner of aggressive control of both asthma and any associated problems that can exacerbate it such as allergies, reflux and sinus disease. With regard to this patient, she is poorly controlled despite frequent physician visits and an aggressive medical regimen. However, prior to performing an invasive procedure such as bronchial thermoplasty, she requires a trial of omalizumab given the allergic nature of her asthma. The patient should receive an adequate treatment with omalizumab prior to consideration for bronchial thermoplasty, or her provider should provide documentation of trial and failure or intolerance to omalizumab prior to consideration for bronchial thermoplasty. Accordingly, the requested bronchial thermoplasty is not likely to be more beneficial for treatment of this patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: A transgender female enrollee has requested authorization and coverage for facial feminization surgery. Studies indicate that facial feminization surgery is medically necessary for the treatment of gender dysphoria in some transgendered individuals. In terms of patient selection, the studies  note that for certain patients an intervention like a reduction rhinoplasty can have a radical and permanent effect on their quality of life, and therefore is much more medically necessary than for somebody without gender dysphoria. The studies recognizes additional surgeries to promote body feminization may include rhinoplastyfacial bone reduction, face-lift, and blepharoplasty. In this case, the patient has been living as a woman for more than 20 years. The patient has been on hormone therapy since she was 14. She had breast augmentation and silicone injections in her hips. The patient continues to suffer from anxiety and distress secondary to gender dysphoria. Facial feminization surgery is a reasonable and necessary next step in the ongoing treatment of this patients gender dysphoria, and is wholly consistent with the recommendations.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 psychiatry, specializes in treating patients with gender dysphoria 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 61-year-old male who has had multiple anorectal surgical procedures. He now suffers from levator ani muscle spasm, and his surgeon has recommended biofeedback and electrical stimulation of the pelvic muscles to treat the condition.  The Health Plan has denied authorization for the therapies based upon a determination that they are not medically necessary.Biofeedback for levator spasm has been shown to be effective in multiple studies in the colorectal literature. The surgical text reference submitted by the patient is one of many sources that support its efficacy. While biofeedback is considered ineffective for many other conditions, it has been shown to be very effective for pelvic floor and anorectal pathology. As the alternative medical therapies are limited to long-term narcotics, sedatives or muscle relaxants (which are not nearly as effective) biofeedback and electrical muscle stimulation are perfectly appropriate therapies in this clinical situation.Based upon the information set forth above, I have determined the requested therapies are medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 10-year-old male enrollee has requested weekly physical therapy for treatment of the enrollees scoliosis and prune belly syndrome.   Findings:  The physician reviewer found that weekly physical therapy by a therapist who specializes in neurodevelopmental treatment and myofascial release is medically necessary for this patients medical conditions. In this case, the patient presents with prune belly syndrome, developmental delay and scoliosis. The requested neurodevelopmental treatment and myofascial release are medically necessary for patients with impaired range of motion due to orthopedic, neurologic and connective tissue etiologies. The medical literature demonstrates the efficacy for intervention using myofascial release for the treatment of children with a variety of neurologic diseases. Thus, the requested services are in accordance with the standard of care in this clinical setting. As such, based on the medical records submitted for review and the medical literature cited above the requested services are medically necessary for this patients medical conditions.
Appeal type: Experimental/Investigational
Decision: Upheld

A 32-year-old male enrollee has requested for ultraviolet A or B phototherapy for treatment of his vitiligo.   Findings:  Three physician reviewers found that there are many therapies for vitiligo including topical corticosteroids, topical immunomodulators, topical calcipotriol ointment, narrowband ultraviolet phototherapy and the Excimer laser. There is no therapy that far exceeds the others in efficacy and most therapies display only mild to moderate improvement in vitiligo. Topical therapies have the benefit of longer usage with few side effects except for cutaneous atrophy with topical steroids.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Oncotype DX testing. Findings:  The physician reviewers found that the current medical evidence has not established the superior efficacy of the services at issue.  Oncotype DX testing has been shown to have prognostic value, but to date has not shown a predictive benefit to standard chemotherapies.  The clinical utility of the services at issue is uncertain.  Per the medical evidence, information is lacking regarding the extent to which assay results do or do not classify patients into distinct groups with clinical relevance.  There is insufficient data to recommend the use of multigene assays, such as Oncotype DX testing, to determine adjuvant therapy.  In this clinical setting, Oncotype DX testing has not been shown to be more beneficial than the standard of care of evaluating risk based on prognostic information from the pathology. In sum, Oncotype DX testing performed was not likely to have been of greater benefit than other modalities for evaluating this patient. Final Result: 2 of 3 reviewers determined that the services at issue 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: All three physician reviewers are board certified in internal medicine with sub-specialty certification in medical oncology 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 54-year-old female enrollee requested authorization and coverage of the medication genotropin. The Health Plan denied the request indicating that the requested medication is not medically necessary for treatment of the enrollees medical condition. One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested medication is not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

A 29-year-old female enrollee has requested residential treatment center level of care services for treatment of her bulimia nervosa and major depressive disorder. Findings:  The physician reviewer found that according to the available peer reviewed medical literature, the patients control of her disturbed eating behaviors was still very tenuous as of the last authorized date of service and she required continued residential level of care for stabilization. She did respond to the treatment intervention; however she continued to struggle with an anxiety problem and distorted body image. This tenuous clinical situation medically justifies the need for appropriate stabilization and aftercare preparation during the dates of service in question.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for DecisionDx-Melanoma Assay testing for evaluation of the enrollees malignant melanoma. Findings:  Three physician reviewers found that the National Comprehensive Cancer Network guidelines indicate that genetic testing such as the DecisionDx-Melanoma Assay should not be used outside of a clinical trial. Moreover, the use of this type of testing is not the standard of care in the treatment of the patients melanoma. The testing at issue is not expected to impact the treatment or outcome of the patients melanoma. Final Result: Three 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 dermatology 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.