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

Findings:  The physician reviewer found that The patient has requested authorization and coverage for expedited scheduling of the corrective spine surgery. Bydon and colleagues report, A trial of conservative therapy may be considered for patients with low-grade spondylolisthesis presenting with radiculopathy and/or pseudoclaudication. These options may include physical therapy, epidural steroid injection, and pain medications. If unresolved, surgical options may include decompression alone or decompression and fusion. Chan and colleagues note, Patients with symptomatic lumbar spondylolisthesis may first be treated with conservative management strategies including, but not limited to, non-narcotic and narcotic pain medications, epidural steroid injections, transforaminal injections, and physical therapy. For well-selected patients who fail conservative management strategies, surgical management is appropriate. Resnick and colleagues explain, As a result of the decompression, the inherent instability associated with the spondylolisthesis may progress and lead to further misalignment that results in pain or recurrence of neurological complaints. Under these circumstances, lumbar fusion is considered appropriate to stabilize the spine and prevent delayed deterioration. In this case, the patient being treated for lumbar spondylolisthesis and presented with low back and left lower extremity L5 pain. The patient reported pain in the setting of L5-S1 isthmic spondylolisthesis with some left whole-body weakness and dropping things with left hand. An examination revealed strength at 5/5 on the bilateral lower extremities and intact sensation at L2-S1 bilaterally. Gait was intact. A computed tomography (CT) scan demonstrated grade 1 anterolisthesis of L5 on S1 with bilateral pars defects noted with bilateral moderate neural foraminal narrowing, along with loss of disc height at L5-S1. X-rays did not show any interval change in grade 1 anterolisthesis of L5 on S1 in flexion and extension. The records noted that the patient was a former smoker. X-rays did not demonstrate instability on flexion/extension. The submitted records did not document red-flag findings such as a loss of control of bowel or bladder function, genital region numbness, progressive weakness, or intractable pain, and there was no documentation from the provider supporting the need for expedited scheduling of the surgery. Therefore, the requested expedited scheduling of the corrective spine surgery is not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested service is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 6-year-old male enrollee has requested applied behavioral analysis (ABA) therapy at a frequency of 25 hours per week and supervision at a frequency of 5 hours per week, for treatment of the enrollees pervasive developmental disorder - not otherwise specified (PDD-NOS), oppositional defiant disorder (ODD) and attention deficit hyperactivity disorder (ADHD).  Findings:  The physician reviewer found that applied behavioral analysis has been shown to be effective in treating behaviors associated with autism spectrum disorder. Treatments based on operant principles of learning are more effective in reducing maladaptive behaviors than alternative treatments. A paper by Warren and colleagues reviewed 34 studies of early intervention in autism and concluded that studies of Lovaas-based approaches as well as early intensive behavioral intervention variants and the Early Start Denver Model resulted in some improvement in cognitive performance, language skills, and adaptive behavior skills (Warren, et al.). However, for those individuals who have been diagnosed with ODD and/or ADHD, in the absence of an autism spectrum disorder, there is no single intervention that emerges as a best treatment for disruptive behaviors (Eyberg, et al.). The most recent psycho-diagnostic evaluation on this patient confirmed a diagnosis of PDD-NOS. Given the patients diagnosis, ABA therapy is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Oncotype DX Prostate Cancer Assay for evaluation of the enrollees prostate cancer. Findings: Two of the three physician reviewers found that several tissue-based molecular assays have been developed in an effort to improve decision-making in newly diagnosed men considering active surveillance and in treated men considering adjuvant therapy or treatment for recurrence. Men with clinically localized disease may consider the use of tumor-based molecular assays. Retrospective case cohort studies have shown that molecular assays performed on biopsy or prostatectomy specimens provide prognostic information independent of National Comprehensive Cancer Network risk groups. These include, but are not limited to, likelihood of biochemical progression after radical prostatectomy or external beam therapy, and likelihood of developing metastasis after radical prostatectomy or salvage radiotherapy.  The medical evidence supports the services at issue in this clinical setting. Final Result: 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 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested inpatient psychiatric hospitalization services for treatment of his behavioral health condition. Findings:  The physician reviewer found that although the patient is diagnosed with a formal thought disorder and has history of non-adherence, the medical record does not support the medical necessity of inpatient level of care.  Per the submitted records, the patient had begun to improve. The notes indicate the patient expressed better insight into his illness and need for treatment. The psychiatrist stated that the patient was not a danger to himself or others. The patient was tolerating his medication with no noted side effects. The notes state that the patient was doing well on his current medication and it was also noted that the patient indicated that he was doing fine. There were no acute issues and both suicidality and homicidal ideation were absent. The patient was noted to have no behavioral issues and he reported that he was feeling better. The patient felt as though he was doing well and he had no anxiety or depression. The psychiatrist determined that he posed no risk to self or others. The nursing notes described a similar reassuring trend. For example, the patient was noted to be isolative; however, his affect, thought processing and thought content were described as appropriate. The patient denied paranoid ideation or auditory hallucinations and felt relaxed.   Further observed and noted were the following: the patient was sleeping 4-6 hours; his activities of daily living and ambulation were fully independent; and the patients mood was described as euthymic. In sum, the record indicates that the illness burden that had initially prompted the patients hospitalization had improved significantly. The patient was stable on medication and independent in functionality. There was no evidence of an acute psychiatric syndrome or medical crisis. Thus, continued inpatient psychiatric hospitalization was no longer medically necessary.  Final Result: The reviewer determined that the services at issue were not and 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: Upheld

A 24-year-old female enrollee has requested residential treatment facility level of care for treatment of her anorexia nervosa.  Findings:  The physician reviewer found that the medical notes indicated that the patient was anxious regarding transferring to a lower level of care.  Progress notes on the said date indicated that she was following the meal plan. The submitted documentation dated the next day indicated that she was doing better and was more compliant with meals. The patient remains in need of intense treatment for her eating disorder, and she is participating in a partial hospitalization program.  Based upon the submitted documentation, residential treatment facility level of care is not medically indicated at this time.  According to American Psychiatric Association guidelines, partial hospitalization is warranted when the patient is cooperative, has at least partial motivation, when intrusive thoughts are present, when structure is needed for weight gain and when there are no major medical complications or severe comorbidity.  All told, the requested residential treatment facility level of care is not medically indicated for this patient.The medical notes indicated that the patient was anxious regarding transferring to a lower level of care.  Progress notes dated 11/12/10 indicated that she was following the meal plan. The submitted documentation dated 11/13/10 indicated that she was doing better and was more compliant with meals. The patient remains in need of intense treatment for her eating disorder, and she is participating in a partial hospitalization program.  Based upon the submitted documentation, residential treatment facility level of care is not medically indicated at this time.  According to American Psychiatric Association guidelines, partial hospitalization is warranted when the patient is cooperative, has at least partial motivation, when intrusive thoughts are present, when structure is needed for weight gain and when there are no major medical  complications or severe comorbidity.  All told, the requested residential treatment facility level of care is not medically indicated for this patient.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for three-dimensional (3D) breast mammography (breast tomosynthesis). The National Comprehensive Cancer Network (NCCN) recommends annual mammogram for the surveillance of patients who are at increased risk for breast cancer and possible tomosynthesis in certain clinical settings. Rafferty and colleagues reported that the addition of tomosynthesis to digital mammography offers the dual benefit of significantly increased diagnostic accuracy and significantly reduced recall rates for noncancer cases. Given this patients personal history of triple negative breast cancer at age 50 and family history of breast cancer, she is considered high-risk. In this scenario, the pee-reviewed medical literature supports the utility of tomosynthesis. Therefore, the requested 3D breast mammography (breast tomosynthesis) is medically necessary for this patient. Final Result: The reviewer determined that the requested services are medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in internal medicine with subspecialty certifications in medical oncology and hematology 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 37-year-old female enrollee has requested bilateral magnetic resonance imaging (MRI) of the breasts performed for evaluation of her left breast lump. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the diagnostic procedure at issue.  The area in question within the left breast on physical examination was equivocal.  Additionally, the presence of augmentation implants complicates the clinical picture, even though conventional imaging with mammography and ultrasound were negative.  In this clinical setting, the presence of an implant could have obscured portions of the breast.  In this patients case, biopsy was not medically reasonable since the area in question was vague on physical examination.  Conventional imaging did not reveal any imaging area of concern.  The current medical evidence supports the requested diagnostic procedure in this case.  All told, the bilateral MRI of the breasts performed on the date indicated was medically indicated for the evaluation of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for Humira 40 mg/0.4 mL.According to the 2019 American College of Rheumatology/Arthritis Foundation Guideline (ACR/AF) for the Treatment of Juvenile Idiopathic Arthritis, in children and adolescents with juvenile idiopathic arthritis and active enthesitis despite treatment with nonsteroidal anti-inflammatory drugs (NSAIDs), using a tumor necrosis factor (TNF) inhibitor, such as Humira, over methotrexate or sulfasalazine was recommended based on the current medical evidence. The ACR/AF guideline also indicates that while TNF inhibitors are preferred, a trial of methotrexate or sulfasalazine may be warranted for patients with contraindications to TNF inhibitors, patients with mild disease, and patients with concomitant active peripheral polyarthritis. Based on the aforementioned guideline, a nonbiologic disease-modifying antirheumatic drug (DMARD), such as methotrexate, is not mandatory for use prior to TNFi therapy, with Humira in this case.In this case, the patient has seronegative spondyloarthropathy/enthesitis type juvenile idiopathic arthritis with persistent ankle pain and swelling. The medical record indicates the patient tried and failed NSAIDs, such as ibuprofen. Therefore, a TNF inhibitor, such as Humira, is appropriate in this setting according to the guideline. The patient does not have a reported contraindication to TNF inhibitor therapy in the medical record. Furthermore, the patient  has  very active inflammatory arthritis with impaired weight-bearing and ambulation as well as active synovitis and erosive change involving the right ankle on imaging. The presence of erosion indicates the disease is advanced and not mild. In addition. the patients disease is reported to primarily involve the right ankle and polyarthritis is not described in this case. In conclusion, the requested Humira 40 mg/0.4 mL is medically necessary for the treatment for the patients medical condition.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 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: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a whole body Positron Emission Tomography (PET) scan.The submitted documentation does not support that the requested service is medically necessary. National Comprehensive Cancer Network (NCCN) Cutaneous Melanoma Guidelines establish that it is standard practice for melanoma in-situ and early invasive melanoma (stage 1A) to be treated with a wide local excision with periodic longitudinal surveillance via clinical examination alone (skin exam, lymph node exam, and review of systems). Under NCCN guidelines, there is no role for a PET-CT scan for surveillance purposes alone. A PET-CT scan might be indicated in the event that a new suspicious mass or unrelenting or unexplainable clinical symptom developed where metastatic disease might be in question. In this case, the submitted records reflect that a PET scan has been requested for surveillance purposes, and there is no indication that a new suspicious mass or unrelenting or unexplainable clinical symptom has developed where metastatic disease might be in question. Under these circumstances, whole body Positron Emission Tomography scanning is not medically necessary to treat the patients medical condition.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 dermatology, with subspecialty certification in dermatopathology, 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

An 18-year-old male enrollee has requested for mental health residential treatment for treatment of her anxiety, depression and substance abuse. Findings:  The physician reviewer found that there appears to be no evidence demonstrating why the patient required residential treatment.It appears that part of the reason for his residential placement was predicated on his refusal to return home. Other placement options could have been considered and would have been available to the patient.
Appeal type: Medical Necessity
Decision: Upheld

A 40-year-old female enrollee requested authorization and coverage of intravenous antibiotic therapy for treatment of lyme disease.  The health plan denied the enrollees request indicating that the requested treatment is not medically necessary.Three physician reviewers performed a medical necessity Independent Medical Review.  All three physician reviewers concluded that the requested treatment is not medically necessary for treatment of the enrollees lyme disease.  Because all three physician reviewers concluded that the requested treatment is not medically necessary for treatment of the enrollees medical condition, the review organization upheld the health plans denial.
Appeal type: Experimental/Investigational
Decision: Overturned

An enrollee has requested authorization and coverage for rib plating surgery (internal fixation of rib fractures) and one day hospital stay.  Findings:  The physician reviewer found that the current medical evidence supports the requested services in this patients case.  The patient had severe trauma resulting in rib fractures.  The original operation involved resecting a portion of several ribs to allow the ribs to fit better together.  This helped for several years.  However, the patient subsequently developed increased instability of the chest wall with increased popping of the overlapping ribs associated with pain.  X-rays confirmed the presence of nonunion of the ribs.  Stabilization of the ribs using a plating system can be expected to benefit this patient and likely is the only surgical treatment that could have such an expected benefit.  Thus, rib plating surgery (internal fixation of rib fractures) and one day hospital stay are likely to be more effective than other methods of treating this patient.  Final Result: The reviewers determined that the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The physician reviewers are board certified in orthopedic surgery, thoracic and cardiac surgery and surgery, respectively, 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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for group 3 power wheelchair with manual recline and multi-power options. Findings:  The physician reviewer found that medical literature supports the use of exercise therapy. Hagen and colleagues note that there is empirical evidence that exercise therapy has beneficial clinical effects for most musculoskeletal conditions. Hastings and colleagues found that manual wheelchair users demonstrated better physical function and mobility than power wheelchair users. In this case, the patient has a history of multiple spinal surgeries. A review of systems did not note difficulty with walking or dizziness, did not document upper body impairments on examination, and documented 4/5 leg strength with intact leg sensation. A durable medical equipment evaluation demonstrated 4/5 upper limb strength and functional range of motion in the upper limbs. The records do not document impairments that would preclude the use of an optimally fitted manual wheelchair to accomplish mobility-related activities of daily living. Therefore, a group 3 power wheelchair with manual recline and multipower options is not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested equipment 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 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: Experimental/Investigational
Decision: Overturned

The parent of a female enrollee requested a Prime super stander chair (E0641) for medical treatment of the enrollees spastic quadriplegic cerebral palsy.  Findings:  Two physician reviewers found that the requested equipment is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. In this case, the patient presents with spastic quadriplegic cerebral palsy, a severe form of cerebral palsy which is characterized by neurological impairment of all four extremities. This patient cannot stand or attempt ambulation unless a supportive system is in place. In general, the standing position is vital to maintain vasovagal sympathetic/parasympathetic responsiveness to prevent hypotension and to maintain varying cardiac tone for circulation.  In sum, the requested Prime super stander chair is widely utilized in the treatment of children with cerebral palsy and is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.