Persius/imr-appeals huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The enrollee has requested reimbursement for the Guardant360 biopsy free tumor sequencing test for evaluation of the enrollees non-small cell lung carcinoma (NSCLC).  Findings:  Two physician reviewers found that adenocarcinoma of the lung should be tested for specific molecular abnormalities, such as epidermal growth factor receptor (EGFR) mutation, ALK, and ROS1 as each of these have therapeutic implications. Such testing is usually done by tissue testing on the biopsy performed. Guardant360 assay is a plasma based assay of multiple molecular profiles. When an EGFR mutation is found and is treated with evidence of progression, Guardant360 assay can be used to detect a further EGFR mutation. Beyond such clinical situation, there is no expected benefit from Guardant360 testing. Final Result: The reviewers determined that the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition. 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: Overturned

Nature of Statutory Criteria/Case Summary:An enrollee has requested authorization and coverage for open magnetic resonance imaging (MRI) for evaluation of the enrollees tendinopathy of the left shoulder. Findings:  The physician reviewer found that the medical literature indicates that MRI is an optimal imaging study to evaluate shoulder anatomy and pathology.  The American College of Radiology has established Appropriateness Criteria (ACR) to evaluate various clinical presentations.  The ACR has established imaging protocols and logarithms to evaluate such entities as low back pain, breast cancer and shoulder pain.  The ACR recommends obtaining plain x-rays as a first line for the evaluation of shoulder pain. However, in their variant 2, it recommends magnetic resonance scanning. The concern in this patients case is whether there are adequate medical indications for an open and presumably lower field strength MRI examination.  The high field strength will produce less patient motion due to shorter scan times. Also, more advanced imaging techniques are available that may not be available on open scanners.  However, in this case, the patient reported extreme claustrophobia.  Therefore, if it is not possible to be scanned on a high field strength magnet, there is support in the literature for using low field strength magnets. Moreover, there are variations in the field strengths in various open magnets available on the market today, ranging from 0.2T to as much as 1.2T.  While it would be preferable to scan this patient on a high field strength magnet, if a surgical intervention is a consideration, then a lower field strength magnet is preferable to no scan at all. As such, the documentation provided as well as the medical evidence support coverage for an open magnetic MRI for the evaluation of this patients medical condition. 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 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: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a myoelectric upper extremity orthosis (HCPCS code L8702). Findings:  The physician reviewer found that a review of 45 trials, Mehrholz and colleagues noted that electromechanical and robot-assisted arm training improved activities of daily living scores, arm function, and arm muscle strength with 95% confidence interval. Peters and colleagues found that for patients with upper extremity impairment, utilization of a myoelectric elbow-wrist-hand orthosis significantly increased gross manual dexterity and performance of certain functional tasks. Willigenburg and colleagues found that myoelectric orthosis increased patient perceptual improvement over the use of no orthosis. Given current medical literature and as the patient has exhausted traditional therapies, the requested device is medically indicated. Therefore, a myoelectric upper extremity orthosis (HCPCS code L8702) is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested device 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 physical medicine and rehabilitation with sub-specialty certification in neuromuscular 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 43-year-old female enrollee requested authorization and coverage of surgical removal of excess skin. The Health Plan  denied the request indicating that the requested surgery is not medically necessary for treatment of the enrollees excess skin status post gastric bypass.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer partially overturned the Health Plans denial on the basis that a portion of the requested surgery is medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The parent of a male enrollee has requested authorization and coverage for in-home applied behavioral analysis (ABA) services for three hours per day, five days per week. Per a study, patients receiving center/community-based ABA services (CBS) had mastered significantly more exemplars and achieved 100% more learning per hour than those receiving home-based ABA services (HBS). The theory in favor of HBS that parents or caregivers are more likely to participate in treatment sessions if the sessions are located in their home. No evidence supporting this theory; rather, the study notes that CBS may provide more structure and a more intentional environment for parents and caregivers to be trained within. [CBS] may allow for more control over the environment and therefore result in a decrease in potential distractors, which may facilitate increased rates of learning.Here, no argument has been presented for why HBS would be more appropriate for this patient than the approved CBS. There are, however, reports from previous HBS providers documenting a need for CBS in order to establish instructional control, reduce disruptions or distractions and to better structure family involvement in sessions. This recommendation is consistent with the above referenced literature. Therefore, the requested in-home ABA services are not medically necessary for treatment of the enrollees condition.Final Result: The reviewer determined that the services at issue 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 psychology, is a board-certified behavioral analyst, and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 15-year-old female who has a history of purging several times a day and had a 25-pound weight loss within 9 months. She has failed intensive outpatient therapy. She is restricting her intake, refusing to attend appointments and was unmotivated for treatment. Her parents are requesting residential treatment for the patient. The Health Plan has denied this request indicating the requested services are not medically necessary.This young woman clearly has an eating disorder with multiple comorbid problems including what appears to be oppositional defiant behaviors/disorder. She has a life threatening illness and is not complying with outpatient therapy. Given the severity of the patients condition and her failure to respond to less intensive treatment, residential treatment services are medically appropriate and indicated. The patient is more likely to benefit from a comprehensive treatment plan with definable goals and interventions. Therefore, I have determined that the requested services are medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Euflexxa injection series in both knees. Findings: This patient presents with bilateral knee osteoarthritis. Treatment has included non-steroidal anti-inflammatory drugs (NSAIDs), corticosteroid injections and physical therapy without substantial benefit. The patients provider noted that the findings on magnetic resonance imaging (MRI) showed a horizontal degenerative tear of the lateral meniscus, articular damage of the lateral tibial plateau, and a small loose body. Physical examination findings noted bilateral positive McMurray signs, bilateral pain with range of motion, and right-sided mild patellofemoral crepitus. Their provider has recommended a series of viscosupplementation with Euflexxa. Evidence from systematic reviews and randomized controlled trials suggests that although viscosupplementation may relieve knee pain in some patients with osteoarthritis, it remains unknown which patients are ideal candidates for treatment. The current evidence is limited, and guidelines from organizations such as the American Academy of Orthopedic Surgeons (AAOS) indicate that the evidence remains inconclusive. As such, the AAOS does not currently support viscosupplementation as standard treatment for osteoarthritis of the knees. In light of the foregoing, viscosupplementation is reserved for patients with a history of lasting benefit from prior injections and when a patients remaining treatment options are limited. In this case, the patients treatment options are limited. The patient has tried and failed conservative modalities with total knee arthroplasty as the remaining alternative. For these reasons, the requested Euflexxa injection series in both knees is medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for an appointment with a psychiatrist that specializes in obsessive compulsive disorder (OCD) at least once per month. The American Academy of Child and Adolescent Psychiatry (AACAP) guidelines recommend starting treatment for OCD with cognitive behavioral therapy (CBT) and a selective serotonin reuptake inhibitor (SSRI). The American Academy of Child and Adolescent Psychiatry (AACAP) noted that combined treatment is more effective than monotherapy for patients with severe OCD. For patients who do not respond, options include raising SSRI dosage, switching to clomipramine, and pursuing various augmentation strategies such as second generation antipsychotics. The appropriate frequency of CBT depends on the severity of the patients symptoms, whether suicidal ideation is present, and the complexities introduced by co-occurring conditions. One specific type of CBT called exposure and response prevention (ERP) has the strongest evidence supporting its use in the treatment of OCD. This type of therapy should be delivered on an outpatient basis weekly or twice weekly depending on the severity of the problem. The records suggest that the patients psychiatric treatment has been consistent with practice guidelines. There is a lack of documentation to support a change in treatment with a psychiatrist that specializes in OCD. Therefore, the requested appointment with a psychiatrist that specializes in OCD at least once per month is not medically necessary for 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 subspecialty 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

The parent of a 17-year-old female enrollee has requested residential treatment for treatment of the enrollees behavioral health conditions.  Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the services at issue.  The medical records document a serious risk of harm due to the patients episodic suicidal ideation.  The clinical notes indicate a history of seizures.  Additionally, the records indicate minimal positive treatment response in the past.  The current medical evidence supports the services at issue in this clinical setting.   This patient was experiencing anxiety and depression symptoms that appeared to improve during her residential treatment stay.  Due to her suicidal actions and thoughts, her poor cooperation in therapy and her anxiety issues, residential treatment services were indicated during the period in dispute.  All told, for residential treatment provided from the date indicated was medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the residential treatment center (RTC) level of care services for treatment of the enrollees polysubstance abuse. Findings:  The physician reviewer found that the patients post-acute withdrawal symptoms were not severe in nature given that the same symptoms were reported during the entire course of his residential stay. He was not a danger to himself or others, nor was he aggressive or violent. He was cognitively intact and he was not gravely disabled. There were no emotional, behavioral, cognitive, or impulsive symptoms that would warrant treatment at the RTC level of care. He was medically and psychiatrically stable, and he was not on any medications when stepped down to RTC. He was engaged in the program and motivated towards sobriety. There was no evidence of a high degree of impulsivity, agitation, depression, mania, hallucinations, or any other significant symptom that would have interfered with his care. He was cooperative and participated in his treatment plan. These findings indicate that the patient could have continued to work on his sobriety, coping skills, and relapse prevention in an ambulatory setting. For these reasons, the RTC level of care services provided were not medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the services at issue were 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 addiction 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 46-year-old female enrollee has requested laparoscopic gastric bypass surgery for the treatment of her morbid obesity. Findings:  The physician reviewer found that with a BMI of 40 and significant comorbid conditions, the patient meets the National Institute of Healths medical necessity criteria for consideration of weight loss surgery. It is highly likely that gastric bypass surgery will ameliorate or eliminate her co-morbid conditions. With regard to the required six months of physician-supervised 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 addition, recent studies indicate that bariatric surgery is associated with decreased over all mortality for the morbidly obese. The psychological evaluation indicates the patient is an acceptable candidate for the gastric bypass procedure.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for anesthesia services provided during a colonoscopy. The Health Plan has denied this request and reported that the services at issue were not medically necessary for the treatment of this patient. Findings:  The physician reviewer found that according to the American Society of Anesthesiologists (ASA) guidelines, monitored anesthesia care is warranted in prolonged or painful procedures such as complex polyp resections, endoscopic retrograde cholangiopancreatography or other biliary procedures, endoscopic dilation, or endoscopic resection. Additionally, the guidelines state that monitored anesthesia care may be necessary for patients with a history of moderate sedation for the procedure or psychological impediments to cooperation. The provided records do not support these criteria.  The records do not document difficulty with intubation, airway obstruction, allergies to sedation medications, chronic alcohol or illicit drug use resulting in increased tolerance to sedation medications. According to the most recent guidelines from the American Society for Gastrointestinal Endoscopy, consciousness during endoscopic procedures is acceptable and is the goal during most procedures. Monitored anesthesia care is recommended for prolonged procedures requiring deep sedation, previously anticipated intolerance to standard sedatives, ASA class IV or V, or risk for airway obstruction due to anatomic variants. The current guidelines do not support the use of monitored anesthesia during colonoscopy in this case. Therefore, anesthesia services provided during a colonoscopy were not medically necessary. Final Result: The reviewer determined that the requested services were 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 gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 52-year-old male enrollee has requested a CT scan of the abdomen for an evaluation of his condition. Findings:  The physician reviewer found that a CT scan is accepted as being medically necessary for abdominal and pelvic trauma, abnormalities noted on other imaging studies, abdominal inflammatory processes (such as abscess, pancreatitis, and colitis), palpable abdominal masses (not explained by other scenarios or other studies), and abdominal and pelvic pain (not explained by clinical features, examination, and preliminary imaging studies such as ultrasound of the abdomen). This patient had upper abdominal discomfort and an EGD revealed gastritis. The abdominal examination was benign with no tenderness, and no palpable masses. The liver panel was essentially unremarkable. The attending physician was suspecting fatty liver or NASH. A good quality ultrasound can be highly sensitive and specific in diagnosing fatty liver. The classic ultrasound findings are hyperechoic liver. An ultrasound of the liver should have been performed first to evaluate for possible fatty liver disease. A CT scan of the abdomen was not the appropriate next step in this setting, and as such, was not medically necessary for this patient.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested inpatient psychiatric and substance abuse hospitalization for the treatment of his behavioral health conditions. Findings:  The physician reviewer found that there is a lack of support for the services at issue in this clinical setting.  The patient was not at risk for imminent severe withdrawals.  His suicidal ideation was passive in nature, and no plan was endorsed.  He denied homicidal ideation.  The patient was medically and psychiatrically stable.  He was not gravely disabled.  He was at his baseline level of mood and affect initially, while towards the end expressing some lessening of negativity of thoughts.   The current medical evidence does not support the services at issue in this clinical setting.  All told, inpatient psychiatric and substance abuse hospitalization were not medically indicated for the treatment of this patient. Final Result: The reviewer determined that the services at issue were 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.