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

A 55-year-old female enrollee has requested adult psychiatric electroconvulsive therapy for treatment of her bipolar disorder. Findings:  The physician reviewer found that ECT is a well-documented safe and effective treatment for bipolar disorder and major depression. This patient has been refractory to many first and second-line treatments, and therefore ECT is a reasonable treatment option. While it can result in cognitive side effects, these have been minimal in this patients case and the associated risk is outweighed by the patients low level of function prior to ECT. American Psychiatric Association Practice Guidelines note that ECT may be considered for patients with severe or treatment-resistant mania, or if ECT is preferred by the patient. In addition, there is evidence to support the use of maintenance/continuation ECT in patients with bipolar disorder (see Schatzberg). Although this patient is not currently on an anti-depressant, she is on a mood stabilizer (Abilify). The absence of an anti-depressant from the patients regimen does not preclude continued ECT as she has a diagnosis of bipolar I disorder and the ECT treatments she has been receiving have likely had anti-depressant properties. For major depressive disorder, the standard of care is to continue anti-depressant medication as long as the risk of relapse is high. Although this standard has also been applied clinically to patients with bipolar depression, the scientific evidence does not support this practice (see Mallah). Furthermore, in the study by Mallah, 33 patients who received anti-depressants for an episode of depression and were followed prospectively over 12 months showed no benefit to continuing anti-depressants, and their time in remission did not differ from that of patients who discontinued anti-depressants. Given the patients many failures of anti-depressant medications, her treating psychiatrist determined that she likely had bipolar disorder and not major depression.  Due to the above factors including the patients poor response to adequate trials of psychiatric medication in the past, her success with ECT, the severe and chronic nature of her illness, and her worsening symptoms and worsening daily functioning without maintenance ECT, ECT was and is medically necessary for this patient
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  The parent of an enrollee has requested growth hormone (GH) Saizen for treatment of the enrollees idiopathic short stature.  The physician reviewer found that this patient has short stature but normal growth velocity given the presence of very early puberty, normal growth factors, a normal GH response on provocative GH testing, and no morphological abnormalities of the pituitary gland or midline brain structures. Thus, he does not have classic GH deficiency. Based on the bone age and height, the estimated final adult height is shorter than expected based on the genetic potential, but not short enough to meet the U.S. Food and Drug Administration (FDA) criteria for a trial of GH therapy for idiopathic short stature. According to  the Pediatric Endocrinology Society guidelines, a trial of GH therapy should be approved for children with otherwise unexplained short stature who pass GH stimulation tests but who meet most of the following criteria: (1) height more than 2.25 standard deviations below the mean for age or more than 2 SD below the mid-parental height percentile; (2) growth velocity less than 25th percentile for bone age; (3) bone age more than 2 SD below the mean for age; (4) low serum IGF-1 and/or IGFBP-3; and/or (5) other clinical features suggestive of GH deficiency. This patient does not meet most of these criteria. Therefore, the requested Saizen is not supported as medically necessary for treatment of this patients medical condition. 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 pediatric endocrinology 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: The patient has requested reimbursement for the Integra for treatment of the enrollees systemic sepsis and necrotizing fasciitis. Findings:  Two physician reviewers found that This patient presented with a significant complex situation as the result of necrotizing fasciitis. She underwent multiple debridement and required extensive reconstruction. As part of this reconstruction, she underwent Integra placement followed by later skin grafting. Integra is used in these types of situations when there are extensive wounds, similar to burn wounds. As noted by researchers, Integra was used in the management of a variety of wounds, including necrotizing fasciitis, extremity degloving injury, meningococcemia, Marjolin ulcer, post-burn lip reconstruction, and fourth-degree burns with exposed bone or tendon. Engraftment rates of Integra and autograft were 98% +/- 4% and 97% +/- 4%, respectively. All areas of graft loss healed without need for regrafting. The benefits of Integra in the management of acute burn wounds can be extended to other traumatic and complex wounds. Standard therapy would include skin grafting without Integra. However, given this patients extensive wounds, the use of Integra allows for thinner skin grafts and/or stabilization of the wounds for later skin grafting. Final Result: The reviewers determined that the service at issue was 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: Reviewers 1, 2 and 3 are board certified in plastic surgery 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: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for gene panel test (CPT codes 81321, 81235 and 81201) for evaluation of the enrollee, who has a history of brain tumor. Findings:  The physician reviewer found that There is a lack of support for the services at issue in this clinical setting.  FoundationOne is a molecular assay that explores the mutations of an individuals cancer cells. The hope is that the assay will identify a specific mutation or target, which could inform the clinician as to which chemotherapeutic drug would be useful. However, there is a lack of convincing evidence that the assay adds to the decision making ability of the clinician or yields a result that is reliably clinically beneficial. There are various nonrandomized studies exploring the value of molecular profiling but these studies are not convincing.  A randomized study by Le Tourneau and colleagues did not demonstrate significant clinical benefit from choosing therapy based on molecular targets. In addition, recent studies have expressed serious reservations about this approach in general. Accordingly, the gene panel test (CPT codes 81321, 81235 and 81201) provided was not likely to have been of greater clinical benefit over the standard options available for the evaluation of this patients medical condition. Final Result: All three 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: Physician reviewer number one is board certified in internal medicine with sub-specialty certification in medical oncology 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 internal medicine with sub-specialty certification in medical oncology 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 internal medicine with sub-specialty certification in medical oncology 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested a peripheral nerve stimulator for treatment of his medical condition.   Findings: The physician reviewer found that while the medical literature supports the use of peripheral nerve stimulator for treatment of chronic cluster headaches and chronic migraines, there is limited data regarding its use for treatment of cervicogenic or post traumatic headaches, such as is the case with this patient. Moreover, there are some studies that identify complications with the implanted nerve stimulator related to lead placement and lead migration. In this patients case, there are other therapeutic options for the treatment of daily headaches that have not been tried and failed. Therefore, in light of the scientific literature and the submitted medical records, the medical necessity of the requested peripheral nerve stimulator has not been established.  Final Result: The reviewer determined that the requested device is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: The physician reviewer is board certified in neurology 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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for upright/standing magnetic resonance imaging (MRI) scan with contrast for evaluation of the enrollees lung cancer. Findings:  The physician reviewer found that the patients desire to avoid ionizing radiation is reasonable if there are adequate alternatives that do not require radiation for completion. The patients concern of coughing, claustrophobia and headache require accommodation if possible. In a patient with such physical limitations, open MRI is an alternative especially if the studies are broken up into three different examinations which will minimize the extended time in the magnet. The open nature of the magnet will alleviate the feeling of claustrophobia and the time spent for each of the three studies will be relatively short. However, the records provided do not support the medical necessity for an upright MRI study in this patients case. Moreover, there is a lack of medical literature demonstrating that an upright MRI would be indicated in lieu of standard imaging. Thus, the requested upright/standing MRI scan with contrast is not medically necessary for evaluation of this patients medical condition. Final Result: The reviewer determined that the requested diagnostic procedure is not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in diagnostic radiology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 52-year-old female enrollee has requested coverage for an MRI for evaluation of her knee pain. Findings:  The physician reviewer found that the American College of Radiology guidelines recommended MRI of the knee when there is concern of internal derangement.  This would include abnormal finding on physical examination, such as locking, abnormal McMurray test, abnormal anterior drawer sign, or abnormal stress maneuvers.  MRI is also appropriate when there is concern of a stress type fracture, suspected infection, loose bodies or suspected tumor.  This patient does not have any clinical evidence of internal derangement.  There is no documentation of clinical suspicion of infection, tumor, stress fracture or loose bodies.
Appeal type: Medical Necessity
Decision: Overturned

An enrollee has requested authorization and coverage for testosterone 1.62% transdermal gel. The submitted documentation supports the requested medication in this clinical setting. Low testosterone can lead to such complications as reduced libido/erectile dysfunction, reduced muscle mass and strength, increased adiposity, osteoporosis/low bone mass, and depressed mood and fatigue. For these reasons, providers often treat patients with hypogonadism when their testosterone level is less than 350 ng/dl. There are a variety of testosterone preparations currently on the market, and injectable and transdermal testosterone preparations are currently the most widely used in the United States. In this case, the patient was unable to tolerate intramuscular testosterone injections. Under these circumstances, testosterone 1.62% transdermal gel is medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested medication 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 internal medicine, with subspecialty certification in endocrinology, diabetes and metabolism, 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 16-year-old male with a history of apparent substance abuse and depression, though the submitted clinical records are generally vague and do not include a detailed history. The records refer to use of alcohol in addition to other substances. The submitted notes, though brief, refer to the patient as cooperative, 12-step compliant, well motivated and pleasant without evidence of withdrawal or any other major psychotic or medical symptoms. At issue is whether the patients continued participation in the residential chemical dependency treatment program is medically necessary.Given the data presented, there is no objective evidence demonstrating the medical necessity of continued residential chemical dependency treatment beyond November 2006. As of the last authorized date of service the patient was motivated, compliant, cooperative and seemingly symptom free. The patient was stable at that point and appropriate for treatment in an outpatient group setting. Therefore, I have determined the requested services are 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: An enrollee has requested StimWave spinal cord stimulator surgery for treatment of the enrollees pain.  Findings: The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  This patient has a history of chronic pain.  The services at issue are not an established treatment for axial back pain.  Riogard and colleagues reported on a small case series of patients with axial pain with some good results.  However, this study has not been replicated.  Song and colleagues also reported on spinal cord stimulation for axial pain, but the results have been mixed.  The current medical evidence does not support the requested services in this clinical setting.  All told, the requested StimWave spinal cord stimulator surgery is not medically indicated for the 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 anesthesiology 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for autonomic nerve testing. Findings:  Two of the three physician reviewers found this patient has been diagnosed with a mitochondrial cytopathy, and he has multiple symptoms suggestive of dysfunction of his autonomic nervous system. He has chronic constipation, excessive sweating, and wide fluctuations of pulse and blood pressure. Use of autonomic nervous system testing is appropriate when signs or symptoms of autonomic dysfunction are present, a definitive diagnosis cannot be made from clinical examination and routine laboratory testing alone, and diagnosis of the suspected autonomic disorder will lead to a change in management or will eliminate the need for further testing. There is support for the requested services in this patients case. The requested services are likely to be beneficial for this patient, as the records noted a history of two cousins with mitochondrial encephalopathy who have died. Clarification of the patients autonomic dysfunction will permit appropriate clinical management. Thus, autonomic nerve testing is likely to be superior over other methods of evaluating this patient. Final Result: The reviewers determined that the requested services are 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 reviewers 1, 2 and 3 are board certified in neurology with special qualification in child neurology 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 reimbursement and authorization and coverage for skilled acute rehabilitation facility services. Findings:  The physician reviewer found that Acute tetraplegia requires complex, individualized rehabilitation to optimize function and maximize health outcomes (Hagen, E.; Nas, K., et al.; Chay, W., and Kirshblum, S.). Even if severe motor weakness precludes the realistic pursuit of full independence with self-care and functional ambulation, there are a number of pragmatic, realistic, appropriate, and warranted functional/therapeutic goals in this clinical setting, including tolerating time out of bed and sitting, dynamic sitting activities, slide board transfers, improving upper body self-care with adaptive equipment, improving skills and independence using a power mobility device, learning to mitigate risk of complications (e.g., autonomic dysreflexia, urinary tract infections, and skin breakdown), and learning to direct care (for future caregivers).In this case, the patient has acute C6 level complete tetraplegia due to trauma as a passenger of a motor vehicle that rolled over. Records reflect that the patient has been making functional progress at the acute inpatient rehabilitation hospital, including in the areas of eating, oral hygiene, grooming, bathing, and upper body dressing. He has been using a power mobility device more independently. These are all appropriate functional issues to continue to address and pursue with skilled rehabilitation services. The patient has not functionally plateaued and further gains are expected. Accordingly, the requested skilled acute rehabilitation facility services were, and are, medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the services at issue and requested services were, and are, 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Anesthetic Injection (CPT64483), Epidural Injection (CPT 64484), and Dexamethasone Sodium Phosphate Injection (HCPCS J1100).In this case, the patient has a history of low back and left hip pain with radiculopathy to the left leg. Records show that the patients pain interferes with activities of daily living. She has reported significant relief of pain and improved activities of daily living with the pain medication Norco. She has been diagnosed with lumbago with left sciatica. She has undergone multiple transforaminal epidural steroid injections on the left at L4, L5, and S1 with reported improvement in pain and function. The patients pain management physician has requested authorization for a left sided transforaminal epidural steroid injection. While current evidence based medical literature supports the use of these injections as an effective treatment for radicular pain due to disc herniation, there is a lack of high-quality evidence demonstrating their effectiveness for the treatment of radicular pain due to spinal stenosis. There is no supporting medical evidence found in literature to support the safety and effectiveness of on-going routine epidural steroid injections for the treatment of radicular low back pain. There is also no evidence in this case of a lumbar spinal pathology, e.g. disc herniation, for which epidural steroid injections are clinically indicated. Accordingly, the requested treatment consisting of Anesthetic Injection (CPT64483), Epidural Injection (CPT 64484), and Dexamethasone Sodium Phosphate Injection (HCPCS J1100) is not medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested services are not medically necessary to treat the patients medical condition. Therefore, the Health Plans denial should be upheld.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.