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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for LINX procedure (CPT 43284). The records provided for review document that this patient has a history of gastroesophageal reflux disease (GERD) with symptoms of voice hoarseness and sore throat, which interfere with his ability to sing as his occupation. The patients provider has recommended the LINX procedure. However, the LINX procedure is not considered the standard of care for patients with GERD due to the lack of rigorous evidence-based literature comparing existing therapeutic interventions for safety, efficacy, and durability over the long-term. Scientific evidence has not been established via well-designed controlled studies with adequate follow-up demonstrating the safety and efficacy of the LINX procedure. Direct comparative studies between surgical interventions are needed to better assess the long-term safety and efficacy of the LINX procedure against other surgical anti-reflux interventions, such as the Nissen fundoplication (Sheu and Rattner). Adverse events including erosion through the esophagus have been reported (Bauer, et al.). Based on current evidence and medical literature, the requested LINX procedure (CPT 43284) is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings:  Two of the three physician reviewers found the requested LINX procedure (CPT 43284) is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewers 1, 2, and 3 are board certified in internal medicine with subspecialty certification in gastroenterology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

A 50-year-old female enrollee has requested for Nuvigil for treatment of her fibromyalgia and depression. Findings:  Three physician reviewers found that There is significant evidence supporting the use of Provigil in this patients case.  In light of the molecular similarity of Nuvigil and Provigil, it is reasonable to assume that the Provigil data can be extrapolated to the use of Nuvigil. Additionally, the patient has shown significant benefit from the use of Nuvigil.  There is also some data to suggest that Nuvigil may have benefit over Provigil. As noted by Darwish and colleagues, at steady state, armodafinil produces consistently higher plasma drug concentrations late in the day than modafinil when compared on a milligram-to-milligram basis. Thus, Nuvigil is likely to be the most efficacious treatment alternative for this patient.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a 17-year-old female enrollee has requested mental health residential center services for treatment of the enrollees behavioral health condition.  Findings:  The physician reviewer found that review of the submitted documentation fails to support that the medical necessity of the mental health residential treatment center services provided from the said date forward. The therapist states that the patient required mental health residential treatment center services level of care as a result of self-harm and suicidal impulses. However, there is a lack of documentation providing a history of these symptoms as well as past medical or psychiatric treatment history. Furthermore, the patients cutting behaviors are documented by the nurse practitioner to be superficial in nature. There is also a lack of documentation describing the exact nature of the patients self-injurious behaviors, including description, frequency and timing of the last episode prior to initiation of treatment. The therapist noted that in a period of six weeks of treatment, the patient underwent three physical holds. However, there is a lack of documentation provided as to what behaviors precipitated the holds or the duration of the holds. All told, the submitted evidence does not establish that this treatment could not have been safely provided at the partial hospitalization program level of care. Thus, based on the documentation provided, coupled with relevant peer-reviewed medical literature and current practice guidelines, the services at issue were not and are not medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the lipoprotein testing (CPT code 83704). Although this patient has a first degree male relative with early coronary artery disease (CAD), she has no other major risk factors for CAD. In addition, she is currently being treated aggressively for hyperlipidemia with medical therapy. Moreover, the patients standard lipid profile is well below goal levels. As she has relatively low risk for CAD and is being treated with maximal drug therapy. According to the American College of Cardiology/American Heart Association (ACC/AHA) guideline goals, there is no data or guideline recommendations that repeated advanced lipoprotein measurements and particle assessments will provide additional clinical information or risk stratification that will direct clinical management. Thus, the lipoprotein testing (CPT code 83704) was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Findings:  Three physician reviewers found the lipoprotein testing (CPT code 83704) was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the lipoprotein testing (CPT code 83704) was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in cardiovascular disease and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for intensive outpatient program services. The Health Plan has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees substance abuse and depression. At issue in this case is whether the requested intensive outpatient program services are medically necessary for treatment of the enrollees behavioral health condition.The American Psychiatric Association treatment guideline for major depressive disorder notes that admission to an intensive day program, may also be indicated for severely ill patients who lack adequate social support outside of a hospital setting, who have complicating psychiatric or general medical conditions, or who have not responded adequately to outpatient treatment. The American Psychiatric Association treatment guidelines for substance use disorders recommends that residential treatment or similar care higher than outpatient is indicated for patients who do not meet the clinical criteria for hospitalization but whose lives and social interactions have come to focus predominantly on substance use.. lack sufficient social and vocational skills and drug-free social supports to maintain abstinence in an outpatient setting.The patient requires a safe and stable living environment in order to develop recovery skills thus qualifying for American Society of Addiction Medicine level III treatment at least i.e. residential or inpatient treatment similar to what patient received at the facility. Patients conditions wax and wane: a relatively positive documentation by one person on one day does not indicate spontaneous cure or that the patient is in the clear, it simply denotes progress and that treatment is working, which is an indication to continue not cease treatment.Given the severe illnesses, continuing to drive despite a driving under the influence arrest and lack of support in the community, treatment with an intensive outpatient program is consistent with standards of good medical practice in the United States, not costlier than an alternative similar service and is thus medically necessary.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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Urolift for treatment of the enrollees enlarged prostate with urinary obstruction. Findings:  2/3 of the physician reviewers found that Urolift is a novel, minimally invasive approach to treating benign prostatic hyperplasia that lifts or holds the enlarged prostate tissue out of the way so it no longer blocks the urethra. Recent clinical trials, including prospective, sham-controlled, randomized studies, have shown that Urolift is safe and effective in relieving lower urinary tract symptoms due to benign prostatic hyperplasia without significantly compromising sexual function. Compared with transurethral resection of the prostate and photoselective vaporization, Urolift is minimally invasive procedure without a requirement of general anesthesia and with a potentially shorter operative time.  In sum, Urolift is likely to be of greater benefit for the treatment of this patient than other available treatment options. Final Result: 2/3 of 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 number one is board certified in urology 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.Physician reviewer number two is board certified in urology 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.Physician reviewer number three is board certified in urology 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 duloxetine HCL 60 mg three times per day for treatment of her neuropathic pain. Findings:  The physician reviewer found that the medical records provided for review document specific antidepressant and anticonvulsant medications have been tried and failed or demonstrated untoward side effects. As such, the medical records indicate that duloxetine is supported for treatment of this patients neuropathic pain. Duloxetine has shown effectiveness for wide variety of neuropathic pain conditions and that dosage of 180 mg per day in select cases has shown benefit when lower doses were not maximal in benefit. The records support that a dosage of 180 mg per day is needed to achieve functional benefit. Lower dosage results in the patient not being able to function. It is reasonable for this dose to be used when other lower doses failed and other medications have failed. Final Result: The reviewer determined that the requested medication 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 neurology with sub-specialty certification in pain medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The patient has requested authorization and coverage for 30-day residential treatment in a post-traumatic stress disorder (PTSD) and trauma recovery program. The American Association of Community Psychiatrists Level of Care Utilization System (LOCUS) provides a reliable framework for determining the appropriate level of care for adults needing mental health treatment. Using LOCUS, providers score patients on a scale of 1-5 using a six-pronged Dimensional Rating System. The six dimensions include: (1) risk of harm; (2) functional status; (3) medical, addictive and psychiatric comorbidity; (4) recovery environment (a. stressors and b. supports); (5) treatment and recovery history; and (6) engagement. The composite score is then used to determine the level of care needed. Applying the LOCUS framework, this patient does not meet the criteria for the requested 30-day residential treatment in a PTSD and trauma recovery program. These findings give the patient a composite score which is consistent with high intensity community based services. Per LOCUS, programs of this type are traditionally clinic-based programs with contact several times per week. For these reasons, the requested 30-day residential treatment in a PTSD and trauma recovery program is not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in 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

A 56-year-old male enrollee requested authorization and coverage of  laparoscopic bilateral inguinal hernia repair for the treatment of an inguinal hernia.  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: 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 breast tomosynthesis is a technique that was developed several years ago as a problem solving adjunct to routine mammography.  Applying the same basic concept as computed tomography (CT) scanning, the logic is that by separating the various layers of breast tissue, one can better detect abnormalities.  This has been shown to be most useful in the evaluation of dense breasts.  It is specifically those patients who have dense breasts that can benefit most from breast tomosynthesis.  Similarly, the areas of asymmetry are appropriately evaluated with breast tomosynthesis.  The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor.  Thus, breast tomosynthesis performed was likely to have been superior over other methods of evaluation. 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

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for Whole Exome Sequencing (WES) diagnostic testing.In this case, the patient has diagnoses of microcephaly, cerebral palsy, hypotonia, absent septum pellucidum, optic nerves hypoplasia, global developmental delay, hydrocephalus, retinopathy and eosinophilic esophagitis (EoE). The patient has been evaluated by a specialist in medical genetics, genetic testing performed to date has been normal, and a well-described genetic condition which would explain the patients findings has not been recognized. Her provider has explained that a positive result from whole exome sequencing would likely enhance medical decision-making, impact the treatment care plan and result in significant clinical impact. If mutations are identified, targeted medical care may be recommended and many of the mutations identified by whole exome sequencing can have associated medical issues, which may alter long term care. The medical literature supports the use of the requested testing under these circumstances. Accordingly, the requested Whole Exome Sequencing (WES) diagnostic test is medically necessary to treat the patients condition, as the results of testing may potentially prevent the progression of disease, disability, and other health conditions as well as prolong life and promote physical health and efficiency.Final Result: The reviewer determined that the requested services are medically necessary to treat the patient's condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in pediatrics and clinical genetics, with subspecialty 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: Upheld

A 39-year-old female enrollee has requested for continued physical therapy for treatment of her chronic lower back pain.  Findings:  The physician reviewer found that there is no documentation of any new injury or condition necessitating additional physical therapy. Continued physical therapy at this time would be maintenance in nature.
Appeal type: Medical Necessity
Decision: Upheld

The patient is 61-year-old female who is requesting coverage for a bilateral surgical brow lift. The submitted information includes a color image of the patient and limited medical records. The provider notes that the patient is concerned about occasional changes in visual acuity, but there are not records of visual testing. The Health Plan does not find that surgical correction of the brow ptosis is medically necessary, and has denied authorization for the procedure.The patient is requesting authorization and coverage for a brow lift.  There is no objective evidence of visual impairment and the photographs do not reveal brow ptosis that could cause a functional defect. The patients brow ptosis in this case is a cosmetic concern.  Therefore, I have determined 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

A 62-year-old female enrollee has requested an MRI of the knee for an evaluation of her knee pain. Findings:  The physician reviewer found that according to the American College of Radiology Appropriateness Criteria, the decision to perform an MRI of the knee should be made after detailed physical examination of the affected joint. The submitted records do not show that such an examination has been performed in this case. Orthopedic evaluation should precede the request for an MRI of the left knee, particularly in this patient who has already had arthroscopic surgery on the same knee.  It may be that an examining orthopedist will recommend an MRI once a detailed physical evaluation has occurred.  However, an MRI of the knee is not medically indicated without such orthopedic evaluation.
Appeal type: Medical Necessity
Decision: Upheld

A 58-year-old female enrollee has requested a panniculectomy/abdominoplasty for treatment of excess abdominal skin.  Findings:  The physician reviewer found that the submitted clinic notes do not contain findings of intertrigo supporting the patients complaints. No accompanying office notes were submitted to document any patient complaints, or more importantly, what treatment was offered to ameliorate the symptoms.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for (1) Synvisc-One (hyaluronan) knee injection and (2) Synvisc-One (hyaluronan) injection in the left knee. 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 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 a history of six months of relief from prior injections received, which allowed her to walk again. Given the patients limited options and based on the current medical literature, the requested services are medically indicated. Therefore, (1) Synvisc-One (hyaluronan) knee injection and (2) Synvisc-One (hyaluronan) injection in the left knee was and is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the services at issue were and 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.