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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for conscious sedation. This patient is scheduled to undergo lumbar facet injections at L3-4 through L5-S1 to test for a possible future lumbar radiofrequency ablation procedure at these levels. The medical records indicate that sedation will be ordered for this procedure. In this case, the clinical notes do not document the need for sedation. Per the medical evidence, the majority of minor pain procedures do not require anesthesia care other than local anesthesia. Medical literature noted that significant anxiety may be an indication for conscious sedation. Medical literature also noted that procedures that require the patient to remain motionless for a prolonged period of time and/or remain in a painful position may require sedation or anesthesia services. In this patients case, the provider did not document an indication for conscious sedation, such as significant anxiety or pain with positioning. The medical evidence does not support the requested services in this clinical setting. Therefore, the requested conscious sedation is 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 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: Medical Necessity
Decision: Upheld

A 52-year-old female enrollee requested authorization and coverage of a laparoscopic total abdominal colectomy with ileorectal anastomosis for the treatment of megacolon and chronic inertia.  The health plan denied the enrollees request indicating that the requested procedure is not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer upheld the health plans denial on the basis that the requested procedure is not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a temporomandibular joint appliance, x-rays (CPT codes 70350, 70355, and 76102), and follow-up office visits (CPT code 99214 x 4). Oral appliance therapy has been shown to be beneficial in patients with TMJ disorder and myofascial pain. TMJ appliances are associated with a decrease symptoms in 70-90% of patients. There are various types of splints used to treat myofascial pain. A single maxillary or mandibular splint is supported for use in this clinical setting. Given this patients history and clinical examination findings, the requested TMJ appliance is medically necessary. The well-accepted standard for the diagnosis of TMJ disorder and orofacial pain is patient history and clinical examination and when indicated, select TMJ imaging. Obtaining TMJ radiographs to determine whether the condyles translate during jaw opening is not indicated as this information can be obtained from physical examination. Therefore, x-rays (CPT code 70355) is medically necessary, while x-rays (CPT codes 70350 and 76102) are not medically necessary for this patient. In addition, the requested four follow-up visits are appropriate to assess the patients response to therapy. Moreover, these appointments will allow the provider to adjust the patients appliance as needed. Thus, the follow-up office visits (CPT code 99214 x 4) are also medically necessary. Final Result: The reviewer determined that a portion of the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned. Credentials/Qualifications: The reviewer is board certified in oral and maxillofacial 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: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for vitamin D screening. Findings:  The physician reviewer found that The clinical manifestations of vitamin D deficiency depend on the severity and duration of the deficiency, with the majority of patients with moderate-to-mild vitamin D deficiency being asymptomatic. Severe Vitamin D deficiency may result in hypocalcemia and bone disorders.   Patient groups at risk for Vitamin D insufficiency may include those taking medications that accelerate the metabolism of vitamin D, those hospitalized or institutionalized with limited effective sun exposure, or those who have dark skin, obesity, osteoporosis, or malabsorption, including inflammatory bowel disease and celiac disease.  Rockwell and colleagues report that no clear evidence supports vitamin D screening to improve health outcomes and that vitamin D screening of the general population is not recommended. LeBlanc and colleagues note that testing for vitamin D deficiency is conducted using 25-hydroxyvitamin D assays. Such testing may be appropriate for patients at high risk for vitamin D deficiency to determine whether supplements are needed. In this case, given that the records do not reflect that the patient has chronic medical conditions that would cause vitamin D deficiency or symptoms that are concerning for Vitamin D deficiency, the service at issue was not medically indicated. Therefore, vitamin D screening was not medically necessary for the evaluation of this patient.Final Result: The reviewer determined that the service at issue was 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 internal medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 31-year-old female enrollee has requested Acthar Gel for treatment of her multiple sclerosis.  Findings:  The physician reviewer found that the submitted documentation establishes the medical necessity of the medication requested. The medical literature supports ACTH for treatment of multiple sclerosis exacerbations and has evidence for being effective in way that steroids are not. As Berkovich notes, Therapeutic mechanisms of ACTH were previously associated (perhaps mistakenly) with only corticotropic actions; however, recently the direct anti-inflammatory effects and immunomodulatory activity of ACTH gel acting through melanocortin pathways have been shown. This patient has a history consistent with multiple sclerosis and has had treatment in the past with Solu-Medrol (methylprednisolone), with described side-effects. According to Myhr and Mellgren, High dose short-term oral or intravenous methylprednisolone for 3-5 days speed up recovery from relapses, but the treatment has no influence on the occurrence of new relapses or long-term disability. Therefore, Acthar Gel is medically necessary as it is likely to be more effective than corticosteroids in this particular case. All told, the medical necessity of the requested medication has been established.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested continuation of transcranial magnetic stimulation (TMS) for treatment of the enrollees major depressive disorder.  Findings: The physician reviewer found that TMS is a non-invasive, neuro-stimulatory intervention endorsed by the American Psychiatric Association (APA) for the treatment of acute phase depression in the adult population. A typical treatment course for TMS is four to six weeks. Avery and colleagues performed an open-label extension study of active TMS in medication-resistant patients with major depressive disorder who did not benefit from an initial course of therapy in a previously reported six-week, randomized controlled study of active versus sham TMS. However, the data used to reach the conclusion was based on an open-label study design. This type of study has the potential for bias since both the patient and the physician know that the active therapy is being provided. This introduces the possibility of an anticipatory expectation that may amplify the placebo effect. At this time, there is a lack of adequately powered, controlled studies showing the benefit of longer courses of TMS therapy. In this case, the patient had no change in two clinical rating scales, and he remained depressed on a third. Further, there was no mention of the specifics of the psychotherapy provided. The most recent medication regimen did not include an antidepressant. Indeed, the combination of lithium and quetiapine is consistent with treatment for bipolar depression which may explain the suboptimal result of TMS thus far as TMS is not approved for bipolarity. In sum, the medical records submitted for review do not support that standard therapies have been exhausted. In addition, the medical evidence does not support a reasonable expectation that continued TMS therapy did or will improve the patients condition or prevent a more serious episode of illness. Accordingly, four unauthorized TMS treatments and 11 more sessions of TMS treatments were not and are not medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the services at issue were not and 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 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 male enrollee requested Harvoni (ledipasvir-sofosbuvir tablets 90-400 mg) for medical  treatment of his hepatitis C.  Findings:  Three physician reviewers found that the U.S. Food and Drug Administration has approved Harvoni for patients with early stage disease.  As noted by the American Association for the Study of Liver Diseases and Infectious Diseases Society of America, the medical evidence supports treatment in all patients with chronic hepatitis C, except those with limited life expectancy due to non-liver-related comorbid conditions.  Earlier initiation of treatment may avoid complications from advanced disease.  All told, the requested Harvoni (ledipasvir-sofosbuvir tablets 90-400 mg) is medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for HP Acthar gel, 80 units twice weekly. Findings:  The physician reviewer found that, as noted in the medical literature, Acthar gel is indicated for treatment of FSGS. While it has been demonstrated to have limited success in treating steroid resistant FSGS, there has been response in some patients. As Acthar gel has been requested for this patient following failure of standard therapies and has been shown to be successful in similar patients, there is an indication for its use in this clinical setting. Given this support, the requested HP Acthar gel, 80 units twice weekly is medically necessary for treatment of this patients FSGS. 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 nephrology 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 30-year-old female enrollee requested authorization and coverage of chronic intermittent intravenous insulin therapy (CIIIT) for the treatment of diabetes.  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 chronic intermittent intravenous insulin therapy (CIIIT) is not likely to be more beneficial for treatment of the enrollees diabetes 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: Overturned

A female enrollee requested Harvoni for medical treatment of her hepatitis C virus genotype 1. Findings:  Two physician reviewers found that the American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) treatment guidelines state that, immediate treatment is assigned the highest priority for those patients with advanced fibrosis (Metavir F3), those with compensated cirrhosis (Metavir F4), liver transplant recipients, and patients with severe extrahepatic hepatitis C.  Based on current data, immediate treatment should be prioritized as necessary so that patients at high risk for liver-related complications and severe extrahepatic hepatitis C complications are given high priority. Thus, the requested treatment with Harvoni is supported as medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 20-month-old male enrollee has requested for speech therapy for treatment of the enrollees delayed speech. Findings:  The physician reviewer found that speech therapy is indicated with any delay greater than 25 % (Law, et al.). Improvements have been noted following speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulty (Law, et al.). Treatment for language disorders is predicated primarily on the childs language profile and level of communication skills (Feldman and Messick). Children who participate in speech-language treatment show better improvement than those children who receive no treatment (Feldman and Messick). Gallagher, et al. evaluated speech and language interventions for preschool children with specific language impairment and found statistically greater improvement with intensive direct speech therapy delivered by speech and language therapists over an eight-month period when compared to no intervention or nursery-based intervention. All told, the requested speech therapy is medically necessary in this patients case.
Appeal type: Experimental/Investigational
Decision: Upheld

A 23-year-old male enrollee has requested collagen cross-links (82523) for treatment of his keratoconus. Findings:  Three physician reviewers found that corneal collagen cross-linking for keratoconus involves an application of riboflavin solution to the eye which is then activated with ultraviolet illumination for 30 minutes. The riboflavin causes new bonds to form across adjacent collagen strands in the corneal stroma which helps to preserve the corneas mechanical strength. The literature contains some articles concerning the merits of the procedure. Hafezi and colleagues cited 10 eyes treated with cross-linking for ectasia after Lasik with two years of follow-up and no progression of the ectasia. However, at this time, the long-term safety and efficacy of the requested services has not been established. In this patients case, alternative treatment options include new contact lens fitting as well as the possible use of corneal Intacs.  In this patients case, collagen cross-links (82523) are not likely to be superior over all other available treatments.
Appeal type: Medical Necessity
Decision: Upheld

The parents of a five-year-old male enrollee requested authorization and coverage of speech therapy twice a week for treatment of the enrollees medical condition. The Health Plan denied the request indicating that the requested therapy is not medically necessary for treatment of the enrollees receptive/expressive language disorder with autism.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested therapy is not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for laser hair (facial) removal for treatment of the enrollees gender dysphoria. Findings:  The physician reviewer found that facial hair removal is within accepted standards of practice and clinically appropriate for treatment of gender dysphoria. Excessive facial hair in a female would be considered abnormal and is referred to as hirsutism. Hirsutism is a medical condition where terminal hair grows in a female in areas that are normally found in males. This would include the face, and parts of the genitalia. A female would be expected to have terminal hair in the scalp, axilla and on the arms and legs. This patients excessive facial hair is more consistent with the male gender. Additionally, the records noted that hormone therapy has not been effective in improving this patients medical condition. The patient reported that she is continually being misgendered. Therefore, laser hair (facial) removal is medically necessary for treatment of this patients gender dysphoria. With regard to whether the requested services are considered reconstructive in nature, excessive facial hair in a female is an abnormal body structure.  Hirsutism is a condition that is congenital in that the hair growth is determined by the genetic and hormonal make-up of the patient. As such, the requested facial hair removal can provide substantial improvement in the appearance of terminal hair and create as normal an appearance as possible. Moreover, the requested services are going to improve emotional function for this patient. All told, laser hair (facial) removal is reconstructive in nature. Final Result: The reviewer determined that the requested services are medically necessary and are reconstructive in nature for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in dermatology 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 62-year-old male enrollee has requested a power wheelchair for treatment of his medical condition.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested equipment.  Powered mobility prescriptions are best completed using a multidisciplinary approach, in order to optimize the appropriateness of the device.  In this case, the patient was assessed by a physical therapist who noted that his mobility issues could be addressed with a front-wheeled walker.  He could also use a manual wheelchair, if needed.  The patient has some mobility impairments, but the records indicate that he is a household ambulator.  Additionally, he has chronic health conditions, such as hyperlipidemia and hypertension, and would benefit from increased physical activity and exercise.  Manual wheelchair use has been shown to provide significant health benefits use over power wheelchair use for persons with mobility impairments.  All told, the requested power wheelchair is not medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for coronary calcium computed tomography (CT). Findings:  Two of the three physician reviewers found there is support for the services at issue in this clinical setting. This patient has some risk factors for coronary artery disease. The records documented symptoms of new onset chest discomfort which could be related to coronary disease despite her relatively lower, but not insignificant, risk profile. There is published data indicating that this modality can provide excellent negative predictive value to rule out coronary artery disease in lower risk, but symptomatic, individuals. All told, coronary calcium CT provided was likely to have been of greater benefit than other methods of evaluating this patient. 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: Physician reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in cardiovascular disease and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 12-year-old male with a diagnosis of autism who has been receiving speech therapy since June 2002. According to documents provided, he has made significant gains in speech during that time. He is now age appropriate for expressive and receptive language skills. He continues to show deficits in problems solving, pragmatic language skills, and verbal language processing. At issue is whether continued speech therapy for the deficits documented is medically necessary.In reviewing the speech therapy reports, I find sufficient documentation that this patient continues to make gains in therapy that warrant continued therapy. Social speech and communication are not solely determined by expressive and receptive language; rather, age appropriate communication also relies on problem solving and pragmatic language skills. Although the literature does not document well the benefits of one-on-one speech therapy for pragmatic speech delay, the patient has experienced significant progression in these areas as documented by the patients therapist. It is well documented in speech therapy texts and developmental pediatrics texts that improvement in speech therapy for a diagnosis of autism is measured in years rather than months. Thus, I find the progress shown in this patient and the expected improvements to be reasonable and predictable. Therefore, I have determined that the requested therapy is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned. The patient should continue to receive speech therapy twice weekly with re-evaluation in six months.