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

A 38-year-old female enrollee has requested transcranial magnetic stimulation (TMS) for treatment of her major depressive disorder.  Findings:  The physician reviewer found that review of the submitted documentation demonstrates the medical necessity of the requested therapy. The peer-reviewed literature continues to demonstrate positivism for TMS while researchers have identified a possible mechanism for the antidepressant effect of TMS (Ueyama et al). Further, TMS has been cleared by the U.S. Food and Drug Administration (FDA) and endorsed by the American Psychiatric Association (APA) in its clinical practice guideline for the treatment of individuals with depression. In this case, the patient is enduring an acute major depressive episode that is causing significant morbidity and functional impairment. Based on the medical records provided, endorsement from the APA and the expanding peer-reviewed literature base, TMS is appropriate to treat this patients depressive symptoms and consistent with good medical practice.  In sum, TMS is a safe and reasonable intervention to treat this patients major depressive disorder at this particular stage of illness, and therefore, medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld

A 63-year-old male enrollee has requested Indium-III Pentetreotide therapy for the treatment of his metastatic carcinoid tumor to the liver. Findings:  Two physician reviewers found that this patient has previously received SIRT twice, and there is concern about radiation dosage to the liver with additional internal radiation therapy. Furthermore, the published studies are Phase I-II studies, and there are no well-designed clinical trials suggesting superior benefits of the proposed treatment. The efficacy of this treatment is yet to be determined. Lastly, this patient has disease not only in the liver but also in the omentum, which probably will not benefit from the requested therapy if given.
Appeal type: Medical Necessity
Decision: Overturned

A 61-year-old female enrollee has requested 3 dimensional bilateral nipple and areolar tattooing for treatment of her medical condition status post bilateral mastectomy due to breast cancer.  Findings:  The physician reviewer found that this patient is documented to have recurrent breast cancer, a history of radiation therapy and is status post bilateral mastectomy. This is an abnormal condition as a result of a malignancy. The bilateral mastectomy has created a significant deformity necessitating complete breast reconstruction, which requires bilateral nipple areolar reconstruction. The requested 3D nipple reconstruction is an attempt to provide a relatively normal appearance of the reconstructed breast. Traditional nipple reconstruction may have a high rate of failure given the history of radiation therapy. The specialized tattooing provides a mean to give the appearance of nipple projection without the inherent risk to traditional nipple reconstruction. Consistent with these findings, the requested bilateral nipple and areolar tattooing with the independent provider is reconstructive in nature and medically necessary for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 44-year-old female enrollee requested authorization and coverage of gastric bypass-duodenal switch surgery for the treatment of morbid obesity.  The health plan denied the enrollees request indicating that the requested treatment is experimental.Three physician reviewers performed an experimental/investigational Independent Medical Review.  Each of the three physician reviewers concluded that gastric bypass-duodenal switch surgery is not likely to be more beneficial for treatment of the enrollees morbid obesity than any available standard therapy.  Because all three physician reviewers concluded that the requested treatment is not likely to be more beneficial for treatment of the enrollees medical condition than any available standard therapy, the review organization upheld the health plans denial.
Appeal type: Medical Necessity
Decision: Upheld

A female enrollee requested the positron emission tomography (PET) with computed tomography (CT) for attenuation (CPT 78815, A9552) for medical evaluation of her hip pain. Findings:  The physician reviewer found that the performance of PET/CT for further analysis of an enlarged lymph node seen on routine imaging modality such as ultrasound is not supported in the medical literature. Since the lymph node could be seen on ultrasound, a sonographic guided biopsy would have been appropriate if the enlarged lymph node persisted over a couple weeks. However, PET/CT was not indicated without a tissue diagnosis indicating malignancy. Thus, the PET with CT for attenuation (CPT 78815, A9552) was not medically necessary for evaluation of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 61-year-old female enrollee has requested for a colonoscopy for evaluation of her risk for colon cancer.  Findings:  The physician reviewer found that a colonoscopy at five-year intervals is appropriate for evaluation and potential treatment for this patient. This screening schedule is consistent with the guidelines discussed by Rex and colleagues which indicates that if a patient has two or more first degree relatives with colon cancer at any age then colonoscopy every five years is recommended.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for monitored anesthesia care for management of the enrollees pain during her colonoscopy. Findings:  The physician reviewer found that according to the American Society of Anesthesiologists (ASA), an essential component of MAC anesthesia is the anesthesia assessment and management of a patients actual or anticipated physiological derangements or medical problems that may occur during a diagnostic or therapeutic procedure. Also, While Monitored Anesthesia Care may include the administration of sedatives and/or analgesics often used for Moderate Sedation, the provider of MAC must be prepared and qualified to convert to general anesthesia when necessary. Additionally, a providers ability to intervene to rescue a patients airway from any sedation-induced compromise is a prerequisite to the qualifications to provide Monitored Anesthesia Care. The medical necessity of MAC takes into consideration many aspects of care including but not limited to the patients ASA classification. The selection and appropriate amount of sedation and/or anesthesia required for colonoscopy is not one size fits all. This is where the clinical judgment of the practitioner comes into play. The ASA practice guidelines and position statement on the use of propofol as noted in the documentation states The society believes that the involvement of the anesthesiologist in the care of every patient is optimal  non-anesthesia personnel who administer propofol should be qualified to rescue patients whose level of sedation becomes deeper than initially intended and who enter, if briefly, a state of general anesthesia.  Propofol is a short acting sedative anesthetic. The onset of action is dose dependent and on average is 30 seconds. The duration of action lasts 3 to 10 minutes depending on the dose. The administration of propofol for a colonoscopy is considered a standard method of anesthesia. The administration of propofol necessitates a practitioner qualified to rescue the patient should they enter a state of general anesthesia. Final Result: The reviewer determined that the services at issue were medically necessary for the treatment of this patient.  Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in anesthesiology 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 45-year-old female with a long-standing history of alcohol and cannabis dependence. She was admitted to inpatient treatment in June 2006 with a history of drinking 18 ounces of hard alcohol and a bottle of wine per day for the past 10 years and smoking marijuana every day for the past 30 years. Her relationship with her significant other was also noted as spiraling downward. The patient noted that her drinking had led to mood swings and much anger. She had also been referred to anger management class due to hostility. Family history was notable for alcohol dependence of her father and her mother who was described as crazy, but no other details are known. During her treatment the patient received Risperdal and Campral. She was also treated with a Librium protocol for detoxification from alcohol.  Finally, she was begun on Wellbutrin XL in July 2006.In July 2006 the patient was noted as tearful, angry, and emotionally labile. In July 2006 she was noted as exhibiting bizarre behavior, exact type unclear, but quite angry.  Later that day, the patient was able to attribute some of her display to abuse she suffered from her mother while growing up, and she appeared more insightful. In July 2006 she was noted as clearer, brighter.The patient has requested reimbursement for her 28-day inpatient stay. The Health Plan has denied this request indicating that inpatient chemical dependency treatment services were not medically necessary beyond July 2006.Review of the submitted clinical information demonstrates the patient had a very sizable history of substance dependence and that this was very much interfering with her domestic life.  It is also apparent that the patient was rather rageful, at least as of July 2006. The exact etiology for this is unclear, though she had somewhat improved by the middle of July 2006 such that she was seen as clearer, brighter.  In general terms, however, given her enormous substance intake over the years, it would not have been appropriate for her to simply detoxify and then leave a protected setting. Clearly, some more in-depth work around what sustained her substance abuse, as well as her depression and anger, was needed to give her any sort of chance to actually remit.  In the context of at least 10 years of heavy substance dependence, 5 days of inpatient treatment was not likely to be satisfactory. All told, I find that the patients 28-day inpatient stay was medically indicated and appropriate. Therefore, I have determined the services at issue were medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Zovirax cream. Findings:  The physician reviewer found that there is a lack of support for the requested medication in this clinical setting. The medical evidence indicates that topical Zovirax (acyclovir) cream is only of modest benefit for the treatment of herpes labialis.  Studies noted the following, Acyclovir cream has been available for the treatment of herpes labialis in numerous countries outside the United States for over a decade. Evidence for its efficacy comes from a few small clinical trials conducted in the 1980sAcyclovir cream did not prevent the development of classical lesions (progression to vesicles, ulcers, and/or crusts). Given the frequency of needed application and modest effect of topical agents, oral antivirals are recommended over topical.  Studies noted, There is also evidence that prophylactic oral ACVmay reduce the frequency and severity of recurrent attack of herpetic infection in immunocompromised patients, but the optimal timing and duration of treatment is uncertain and can vary in different situations. In this patients case, there is no documented herpes simplex virus type 1 infection but there is presumed infection.  Moreover, the studies show that there is no contraindication to the use of oral medications in this patients case, although the patient had reported some gastrointestinal upset with oral agents. The medical literature recommends a trial of oral agents given the improved response. As such, the request for Zovirax cream is not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested medication is 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 internal medicine with sub-specialty certification in rheumatology 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

An female enrollee has requested water circulating cold pad with pump for treatment of her right knee status post total knee arthroplasty. Nature of Statutory Criteria/Case Summary:   Three physician reviewers found that a review of the current medical literature on continuous cryotherapy after total knee arthroplasty resulted in a paucity of high quality data. Several recent meta-analyses failed to demonstrate any significant improvements in postoperative range of motion, reduced blood loss or reduced postoperative drainage with continuous cryotherapy over standard ice packs. A systematic review by Cina-Tschumi concluded that solely an analgesic effect was demonstrated by the use of continuous cooling. Another systematic review by Adie and colleagues concluded that, despite some early gains, cryotherapy after total knee arthroplasty yields no noted lasting benefits. All told, the water circulating cold pad with pump was not likely to have been more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: Three reviewers determined that the device 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: All three reviewers are board certified in orthopedic surgery 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 parent of a 23-month-old male enrollee has requested  speech therapy for treatment of the enrollees delayed speech.  Findings:  The physician reviewer found that this 23-month-old patients speech is at a one-year level.  His speech is significantly delayed, both by parental description and formal testing.  The etiology is due to a severe developmental delay in the maturation of speech. It was noted that the patient does not demonstrate a developmental speech and language delay, however an in-plan speech pathologist, after testing the patient, diagnosed him as developmentally delayed in speech.  Regarding medical necessity, it is the medical communitys standard practice to offer speech therapy to a two-year-old whose speech is at a one-year level.  There is robust medical literature supporting speech therapy in this speech delayed population. Law, et al. reported that children with speech delay can be readily treated. Goorhuis-Brower, et al. specifically deals with speech-delayed children and points out that such children are candidates for successful speech therapy.  Two-year olds, who tested below the 10th percentile, as did this patient, do require and benefit from speech therapy (Emmanuel, et al. and Buschman, et al.).  In sum, speech therapy is medically indicated in this patient, with reevaluation after six months.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the digital breast tomosynthesis performed for evaluation of her breast cancer examination. Findings:  Three physician reviewers found that tomosynthesis is a technique that was developed as a problem solving adjunct to routine mammography. In this case, the patient has extremely dense breast tissue. While one could make the argument that her mammogram has not changed since the last study, it is specifically those patients who have dense breasts that can benefit most from tomosynthesis. The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor. The 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: Reviewers 1, 2, and 3 are board certified in diagnostic radiology 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: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Euflexxa injections for treatment of her medical condition.  Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested services.  Researchers performed a meta-analysis of 137 studies with 33,243 participants and concluded that hyaluronic acid was the best pharmacologic intervention for knee osteoarthritis.  Hyaluronic acid was found to be better than injected placebo or injected corticosteroids.  Another study conducted a systematic review on the efficacy and safety of repeat courses of hyaluronan therapy in patients with osteoarthritis of the knee and concluded that repeat courses of the hyaluronans were safe and effective in the treatment of pain associated with osteoarthritis of the knee.  The evidence-based peer-reviewed literature supports the use of repeat series of viscosupplementation injections for the treatment of pain in patients with osteoarthritis of the knee.  All told, the requested Euflexxa injections are medically indicated for the treatment of this patient. Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: The reviewer is board certified in orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Urgent Care
Decision: Upheld

A 48-year-old female enrollee has requested emergency services for the treatment of her condition. Findings:  The physician reviewer found that this patients symptoms were not sudden in onset, but had been present for one month. She was described as healthy-appearing and non-toxic. She was not experiencing chest pains or shortness of breath. She did not require any testing or treatment in the emergency department. In sum, this patients symptoms did not meet the criteria for an emergency medical condition. A prudent layperson with an average knowledge of medicine and nasal congestion, cough, body aches and headache would not reasonably expect the absence of emergency care to jeopardize their health. This patient could have been safely evaluated on a non-emergent basis.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 51-year-old diabetic man with cellulitis of the left foot associated with an old recurrent ulcer related to an operative procedure performed in 1985. It does not appear to have been associated with osteomyelitis.  The patient was given Cipro followed by Levaquin. Follow-up cultures in July 2005 grew methicillin resistant staphylococcus aureus (MRSA). There was sensitivity to clindamycin, gentamicin, rifampin, tetracycline, trimeth/sulfa and vancomycin. Zyvox was then ordered by the patients podiatrist. At issue is whether Zyvox was medically necessary for treatment of the patients condition.The Health Plans denial should be overturned. Zyvox is accepted as an appropriate alternate to IV vancomycin. The studies referenced above support the use of Zyvox in the treatment of patients such as this patient. As such, the use of Zyvox in this instance was medically reasonable and appropriate and should be covered by the Health Plan. Accordingly, I have determined that the medication at issue was medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for laparoscopic gastric bypass/Roux-en-Y gastroenterostomy for treatment of the enrollees medical condition. Findings:  The physician reviewer found that this patient meets standard criteria for bariatric surgery based on published guidelines.  The medical records document morbid obesity, as the patient has a BMI that is greater than 40.  Specifically, the clinical notes indicated a BMI of 59.2.  This patient has completed a multidisciplinary evaluation that did not reveal any obvious behavioral, dietary or medical barriers to surgery.  The patient has failed dietary efforts in the past.  The current medical evidence supports the services at issue in this clinical setting. 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 surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Harvoni for 12 weeks for treatment of her hepatitis C virus (HCV).  Findings:  The physician reviewer found that according to the American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) Successful hepatitis C treatment results in sustained virologic response (SVR), which is tantamount to virologic cure, and as such, is expected to benefit nearly all chronically infected persons. Evidence clearly supports treatment in all HCV-infected persons, except those with limited life expectancy (less than 12 months) due to non-liver-related comorbid conditions. Per AASLD/IDSA guidelines Harvoni for 12 weeks is recommended for treatment-naive patients with HCV genotype 1 infection. Therefore, Harvoni should be approved as medically necessary based on national guidelines. 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 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.