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

A 64-year-old female enrollee has requested general anesthesia  for treatment of her hypertension.  Findings:  The physician reviewer found that the submitted medical records do not demonstrate the medical necessity of the services at issue.  This patient has a history of hypertension.  However, general anesthesia was not medically indicated in this clinical setting.  The patient did not present with a significant history that would require general anesthesia.  Additionally, there is a lack of clinical notes documenting comorbid conditions that would place the patient at risk for complications requiring the need for general anesthesia.  The current medical evidence does not support the use of general anesthesia in this patients case.  All told, general anesthesia administered during the tooth extraction on the date indicated was not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 49-year-old female who is 52 and weighs 190 pounds. Her medical history is significant for diabetes mellitus, hypothyroidism, systemic hypertension, obesity, and previous tobacco use. She also has a history of a work-related back injury. The patient states she has pain in her neck, shoulder, and upper and lower back. Her provider indicates x-rays show thoracic strain as well as L4-L5 spondylolisthesis. Upon examination, the patients plastic surgeon noted significant abdominal dermatochalasis and a large abdominal pannus. A wide abdominal rectus plication (WARP) procedure was recommended. The Health Plan has denied coverage for the WARP procedure on the basis that it is not medically necessary. The patient wishes to undergo a WARP procedure to address her chronic back pain. She has been told she is not a good candidate for back surgery and she has refused gastric bypass surgery to address her obesity, which appears to be a contributing factor to her back pain based on the medical evaluations provided. The literature regarding the WARP procedure is minimal and controversial. The likelihood that this procedure will result in improvement in the patients back pain has not been established to the point that it can be considered a viable therapeutic option. There are more predictable therapeutic options available to this patient than the WARP procedure. Therefore, I have determined that 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: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested rhinoplasty for treatment of his nasal fracture and deviated nasal septum.  Findings:  The physician reviewer found that from the American Society of Plastic Surgeons (ASPS), reconstructive surgery is performed on abnormal structures of the body, caused by congenital defects, developmental abnormalities, trauma, infection, tumors or disease. It is generally performed to improve function, but may also be done to approximate a normal appearance. In addition, the ASPS noted that reconstructive rhinoplasty transforms nasal abnormalities or damaged nasal structures to a more normal state. In the medical literature, Howard and Rohrich noted that in patients with nasal airway obstruction, it is important to restore the nasal airway. This patient presents with evidence of residual deformity and nasal obstruction as well as symptoms following attempted treatment with nasal fracture reduction. His initial treatment consisted of nasal fracture reduction which was unsuccessful. The patient has nasal deformity and nasal airway obstruction as a direct result of an initial injury and failed treatment. Based on the patients complaints and review of the photographs, secondary nasal treatment is within the standard of care from a reconstructive standpoint. Consistent with these findings, the requested corrective rhinoplasty is reconstructive in nature and medically necessary for management of this patients significant nasal dorsal, nasal bone and septal deformity.  Final Result: The reviewer determined that the requested surgery is reconstructive in nature and medically necessary for treatment of the patients medical condition.  Credentials/Qualifications: The reviewer is board certified in plastic 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:An enrollee has requested reimbursement for immunoglobulin G (IgG) testing (CPT 86001 x 6) for evaluation of the enrollee, who reported a history of chest tightness and pressure. Findings:  The physician reviewer found that allergic bronchopulmonary aspergillosis (ABPA) is an immunologic bronchopulmonary inflammation due to an immune response against Aspergillus fumigatus. The major clinical features of ABPA include asthma, recurrent pulmonary infiltrates, immediate wheal-and-flare skin reactivity to Aspergillus fumigatus, elevated total serum immunoglobulin E (IgE) levels, detectable serum precipitating antibodies to Aspergillus fumigatus, peripheral blood eosinophilia, elevated levels of Aspergillus-specific serum IgE and central bronchiectasis. The diagnosis of ABPA should be suspected in asthmatics or patients with allergic disease, with evidence of central bronchiectasis or recurrent atelectasis in chest imaging. The medical evidence support further evaluation in this setting. In this patients case, the clinical data are sufficient to support a high clinical suspicion for ABPA to warrant the tests in review. Therefore, the services at issue were likely to have been of greater benefit than other methods of evaluating this patient.  Final Result: Two of 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: Physician reviewer number one is board certified in allergy and immunology 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 allergy and immunology 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 allergy and immunology 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

A 59-year-old male enrollee has requested intensity modulated radiation therapy for treatment of his gastric cancer.  Findings:  Two physician reviewers found that three-dimensional conformal radiation therapy is the standard of care for radiation therapy treatment of gastric cancer. There are a few publications in the literature suggesting improved coverage of target and reducing radiation dose to nearby sensitive organs. However, these are small single institution studies with a few patients. In a paper by Minn, et al., IMRT was found to result in sparing of liver and possibly renal function. A study by Alani, et al. found that IMRT confers only a marginal benefit in the adjuvant treatment of gastric cancer and should be used in a small subset of patients with risk factors for kidney disease or those with a preexisting nephropathy. There are no randomized or large cohort trials suggesting improvement in clinical outcome with the use of IMRT versus 3D conformal radiation therapy. Thus, IMRT was not likely to be more beneficial than standard radiation therapy for this patient.
Appeal type: Medical Necessity
Decision: Upheld

A female enrollee requested Orthovisc or Synvisc injections for medical treatment of her left knee osteoarthritis.  Findings: The physician reviewer found that the records submitted for review indicate the patient has had Synvisc and Orthovisc knee injections which were reported to be beneficial. However, there was a lack of documentation of clinical improvement from the initial course of injections evidenced by improvement in pain utilizing the visual analog scale (VAS), objective functional improvement evidenced by range of motion values, an increase in daily activities, reduction in dose of nonsteroidal anti-inflammatory drugs (NSAIDs) or a reduction of intra-articular steroid injections for the six month period following the Orthovisc injection. Based on the peer-reviewed literature and clinical documentation, the requested Orthovisc or Synvisc injection is not medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

A 57-year-old female enrollee has requested hyaluronate injections for treatment of osteoarthritis. Findings:  Two physician reviewers found that the requested series of hyaluronate injections is medically reasonable in this patient for her recurrent ongoing arthritic knee complaints. Other treatment options seem to have been tried in terms of over-the-counter medication, physical therapy and activity modification. Often in these cases, knee replacement surgery is the only other option that is likely to be of benefit. In this case, since this patient had good relief from the injections for at least one year, it is medically reasonable to repeat the injections at this time in an attempt to give her ongoing comfort without the need for surgical intervention.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for clarithromycin (500 mg, two tablets once per day), rifampin (300 mg, one capsule twice per day), Malarone (250 mg, once per day), fentanyl transdermal patch (75 mg), and Norco (10-325 mg, once every six hours)for treatment of the enrollees diagnosis of Lyme disease.  Findings:  The physician reviewer found that this patient with Lyme positive testing received treatment with ceftriaxone which is indicated for patients with neuro-Lyme disease. Repeat testing for Lyme was negative per the records provided for review. Rifampin is a commonly used antibiotic not indicated for the treatment of Lyme disease. In addition, while there may be some efficacy of clarithromycin, it is not considered the standard of care when there are better, guideline based agents for the treatment of Lyme disease. Malarone is indicated for malaria and not Lyme disease. Atovaquone has been used for Babesia. The fentanyl patch and Norco are not indicated in the treatment on Lyme disease, but for pain. For those reasons, clarithromycin (500 mg, two tablets once per day), rifampin (300 mg, one capsule twice per day), Malarone (250 mg, once per day), fentanyl transdermal patch (75 mg), and Norco (10-325 mg, once every six hours) are not medically necessary for the treatment of this patients medical condition. Final Result: The reviewer determined that the requested medications 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 internal medicine with sub-specialty certification in infectious disease 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: A 39-year-old female enrollee has requested authorization and coverage for Botox injections. As discussed by the American College of Obstetricians and Gynecologists (ACOG), vulvodynia is often difficult to treat and requires treatment tailored for each individual patient. Botox is not a first-line treatment for vulvodynia. However, the mechanism of action corresponds with the treatment needs of this patient. Studies have shown that Botox can be helpful for refractory cases of persistent pelvic pain. This patients symptoms have not improved with physical therapy, medications and psychotherapy. Thus, the requested Botox injections are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.One reviewer found that the requested Botox injections are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: Two of the three 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:  One reviewer is board certified in obstetrics and gynecology and is actively practicing. One Reviewer is board certified in obstetrics and gynecology and is actively practicing.  One Reviewer is board certified in obstetrics and gynecology and is 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 reimbursement and prospective authorization and coverage for 40 hours per week of direct applied behavioral analysis (ABA) therapy that was provided. Findings:  The physician reviewer found that studies evaluated the relationship between ABA treatment intensity and treatment outcomes for individuals with ASD. The studies found that a strong relationship between treatment intensity and mastery of learning objectives, where higher treatment intensity predicted greater progress was demonstrated. The studies concluded that These results add to the existing support for higher intensity treatment for children with ASD. The Behavior Analyst Certification Board indicate that typical comprehensive ABA programs range from 30 to 40 hours of treatment per week. In this case, the patient has made progress in many areas as evidenced by the progress reports, however he continues to demonstrate noncompliance in addition to level 2 vocal, physical and visual stereotypies. Based on the clinical documentation submitted for review, the request for 40 hours per week of direct ABA therapy provided has been established as medically necessary for treatment of the patients ASD. Final Result: The reviewer determined that 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 physician reviewer is board certified in pediatrics with sub-specialty 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Repatha for treatment of the enrollees elevated low density lipoprotein (LDL) cholesterol. Findings:  The physician reviewer found that the requested use of Repatha in this patients case is in concert with the U.S. Food and Drug Administration (FDA) recommendations for use of the PCSK9 inhibitors for treatment of lipids. Repatha, the second drug approved in a new class of drugs known as PCSK9 inhibitors, has been approved for use in addition to diet and maximally-tolerated statin therapy in adult patients with heterozygous familial hypercholesterolemia (HeFH), homozygous familial hypercholesterolemia (HoFH), or clinical atherosclerotic cardiovascular disease, such as heart attacks or strokes, who require additional lowering of LDL cholesterol. Given these findings, the requested Repatha is supported as medically necessary for treatment of this 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 cardiovascular disease 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 representative of a 56-year-old male enrollee has requested for continued care at a skilled nursing facility (SNF) for treatment of his cerebral vascular accident (CVA).    Findings:  The physician reviewer found that there is no expectation that continued daily skilled rehabilitation services will significantly alter the patients functional status. He continues with a dense hemiparesis and has made excellent functional progress. However, without more neurological recovery he is not expected to experience additional functional recovery with skilled rehabilitation. The literature is very clear  skilled rehabilitation does not increase neurological recovery. Additionally, the level of function the patient has reached places him at a level that no longer requires inpatient services. His needs for assistance could be met at a lower level of care.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:   An enrollee has requested MiMedx amnion graft applications for treatment of her medical condition.  Two physician reviewers found that there is sufficient support for the services at issue in this clinical setting.  This patient did not respond to accepted conservative tissue management.  Per the records, the patient experienced an excellent outcome, with a rapid response to treatment.  Alternative treatments for the patient included negative pressure therapy, hyperbaric oxygen therapy, progressive surgical debridement, specialty dressings, split thickness grafting and stem cell grafting.  In this case, there is support for the use of amniotic grafts.  All told, MiMedx amnion graft applications were likely to have been more effective than other treatment options.  Final Result: Two reviewers determined that the services at issue were 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: All three reviewers are board certified in podiatry 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: Upheld

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for residential treatment center services. Recent progress notes indicate the patient is participating in a partial hospitalization program. The partial hospitalization program notes indicate that the patient has been cooperative in treatment. He has not reported suicidal or homicidal ideation while in the program. It appears that his symptoms overall have been well-controlled while in the partial hospitalization program. The American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists Child and Adolescent Level of Care Utilization System (CALOCUS) provides a reliable framework for determining the appropriate level of care for adolescents needing mental health treatment. In terms of risk of harm. The medical records indicate that the patient was not actively suicidal. He does have impulsive behaviors with physically aggressive impulses. The patient has had issues with level of function due to mental illness, but overall showed appropriate daily functioning while in treatment, including cooperation in treatment and intact activities of daily living. The patient does not have active medical problems or substance use that affects his primary psychiatric issues. This correlates with intensive outpatient services. Therefore, residential treatment center services are not medically necessary 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 psychiatry with sub-specialty certification in child and adolescent 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 36-year-old male has requested gastric bypass surgery without a 10% preoperative weight loss for treatment of the enrollees morbid obesity.  Findings:  The physician reviewer found that this patient clearly meets the criteria set by the National Institutes of Health for surgical treatment of obesity with a BMI of 77.3 and severe comorbidities that will likely be ameliorated or eliminated by bariatric surgery. With regard to the 10% preoperative weight loss, there is no scientific evidence demonstrating that structured diet or exercise plans have been successful in the treatment of the morbidly obese. In fact, the Swedish obesity study identified that even though there may be reduction or resolution of some symptoms with diet and exercise, surgery has the longest and best long-term outcome for the morbidly obese. In addition, recent studies indicate that bariatric surgery is associated with decreased over all mortality in this population.