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

Nature of Statutory Criteria/Case Summary:  An enrollee has requested genetic blood testing for evaluation of her Ehlers-Danlos (EDS) syndrome.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate that the blood genetic testing is medically necessary at this time. While the patients history of hyper-mobile joints, gastrointestinal problems and hernia may indicate that the patient has EDS, before any testing is appropriate, a clinical genetics evaluation to determine the type of EDS is the initial step. There is no submitted record of a clinical genetics evaluation. If the patient is diagnosed with hyper-mobility type of EDS, no testing is available.  On the other hand, if the patient is determined to have an alternative form of EDS, then testing for this type of EDS is available and could be considered.  Based on the patients submitted records, the requested genetic blood testing is not medically necessary in the evaluation of her medical condition at this time. Final Result: The reviewer determined that the requested service is not medically necessary for evaluation of the patients medical condition at this time. Therefore, the Health Plans denial should be upheld at this time.  Credentials/Qualifications:  The reviewer is board certified in clinical genetics 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 32-year-old male enrollee has requested acute inpatient mental health services for treatment of his behavioral health issues.  Findings:  The physician reviewer found that utilizing the American Society of Addiction Medicine (ASAM) criteria for a Level III residential treatment center (RTC) this patient was not described to be at risk for withdrawal. In addition, he did not require medical monitoring and he did not attend the groups as would be expected. As such, during the said time frame, the patients psychiatric condition did not require the 24-hour structured setting in a RTC and treatment could have been provided at a lower level of care. Consistent with these findings, the acute inpatient hospitalization for stabilization during this time met the criteria set forth by the ASAM as medically necessary. However, the patient did not meet the ASAM criteria for the Level III RTC facility from the said dates and could have been treated in a less restrictive environment.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Repatha 140 mg/ml Sureclick subcutaneous every two weeks for treatment of her hyperlipidemia. Findings:  The physician reviewer found that the records document known coronary disease and persistently high LDL cholesterol despite maximally tolerated statin dose and a trial of Zetia.  Repatha is a proprotein convertase subtilisin kexin (PCSK9) inhibitor studied in and approved for patients with heterozygous familial hypercholesterolemia or for patients with documented atherosclerotic heart disease who require additional lowering of LDL cholesterol.  This patient fits the latter criteria. Randomized clinical trials have demonstrated effective LDL lowering in this setting as well as improvement in cardiac outcome in post hoc analyses.  The medical evidence supports the requested medication in this clinical setting.  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

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for spinal surgery (CPT Codes 22614, 22612, 22558, and 22585). Updated guidelines by Eck and colleagues for lumbar fusion in situations of back pain without stenosis or spondylolisthesis note that inherent to such situations is the inability to identify the source of patients' pain. They conclude that under these circumstances the best evidence supports that a comprehensive rehabilitation program is as effective as lumbar fusion. These guidelines recommend lumbar fusion only for patients who fail conservative care. In the same series of practice guidelines, Resnick and colleagues conclude that lumbar fusion is an appropriate treatment option for lumbar stenosis with spondylolisthesis. Yavin and colleagues also conclude that fusion is most efficacious in patients with spondylolisthesis. In other situations, the risk benefit ratio requires meaningful caution to be observed.In this case, there is a major discrepancy between what is interpreted on the patient's imaging studies by the surgeon and the radiologist. In the setting of a major discrepancy in the radiology interpretation, it is difficult to discern the etiology of the patient's pain. Based on the submitted documentation, it is not clear exactly what pathology is present in the patient's lumbar spine. As noted above, lumbar fusion has been found to be an appropriate treatment option for lumbar stenosis with spondylolisthesis, however, there are limited to no data in the submitted records that reflects that these pathologies are present in this case. Therefore, there is insufficient evidence on imaging to suggest that there is pathology that warrants the requested spinal surgery. In addition, there is no documentation in the submitted records that the patient has attempted an aggressive non-surgical rehabilitation that includes physical therapy to treat her symptoms since her fusion surgery. Exhaustive non-surgical strategies do not appear to have been performed since the patients surgery. Furthermore, there is no evidence of spinal instability present to suggest that additional fusion surgery is required at this time. Under these circumstances, the requested spinal surgery (CPT Codes 22614, 22612, 22558, and 22585) is not medically necessary to treat this patients medical condition.Final Result: The reviewer determined that the requested services are not medically necessary to treat this patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in neurological 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for weekly individual psychotherapy services. The submitted documentation supports the medical necessity of the requested services. A review of randomized trials of adjunctive psychotherapy for bipolar disorder concluded that, [A]djunctive psychotherapy enhances the symptomatic and functional outcomes of bipolar disorder. A review of outcome studies of psychological interventions noted that, `[B]ipolar disorder is often only partially treated by medication alone ... a range of psychological approaches appear to benefit people with bipolar disorder.` These studies reflect that psychotherapy has been shown to help reduce patients symptoms in the context of bipolar disorder. Like any other treatment, however, psychotherapy needs to be continued for maintenance, as bipolar disorder is not curable, but is at least manageable and treatable. The standard of maintenance psychotherapy is weekly, which is appropriate to treat the patients condition, and is consistent with good medical practice. Accordingly, weekly individual psychotherapy services are medically necessary for treatment of the patients medical condition.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 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested methadone (50 mg capsule form) for treatment of the enrollees chronic pain. Findings: The physician reviewer found that Based on the medical literature and the presented clinical records, methadone (50 mg capsule form) is not medically necessary. The requested dosage and quantity are only indicated for malignant pain. The medical records show the patient to have chronic non-malignant pain. The current standard of care for chronic pain associated with disc herniation or joint disease is treatment in a multidisciplinary practice that includes physical therapy, massage therapy, behavioral therapy, and steroid injections. Based on a study by Mafi and colleagues there are Well-established guidelines for routine back pain stress conservative management, including use of nonsteroidal anti-inflammatory drugs (NSAIDs) or acetaminophen and physical therapy. There are a variety of anticonvulsants and anti-depressants considered adjunctive to pain management therapy. High dose opioids are associated with a high risk of dependence and tolerance and are therefore not recommended. Short-acting opiates are more likely to cause adverse outcomes. Therefore, methadone (50 mg capsule form) to be picked up at a local Kaiser facility is not medically necessary in this clinical setting.Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in 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: Overturned

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for Dupixent (dupilumab) 20 mg/1.14 mL Valbuena and colleagues describe actinic prurigo as a chronic photodermatosis with onset in childhood or before 20 years of age. It is a rare condition without a clear optimal therapy or guidelines for management. In this case, the patient has recurrent disease. Given that the patient has tried and failed multiple therapies and the good safety profile of Dupixent generally, the requested medication is medically indicated as the next step in therapy for this patient. Therefore, Dupixent (dupilumab) 20 mg/1.14 mL is medically necessary for the treatment of this patient. 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 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: Overturned

Nature of Statutory Criteria/Case Summary:   The parent of an enrollee has requested mastectomy gynecomastia, suction assisted lipectomy trunk (CPT 15877) for treatment of the enrollees gynecomastia.  The physician reviewer found that with regard to whether the suction assisted lipectomy trunk (CPT 15877) meets reconstructive surgery criteria, the patient presents with gynecomastia, an abnormal excess of male breast tissue. This is likely caused by developmental abnormalities that have not resolved with time. There is no evidence that liposuction would help to improve function or create a normal appearance to the extent possible. However, the requested mastectomy would likely contribute greater to an improvement in the patient's functional deficit of pain. In addition, liposuction does not offer more than a minimal improvement in the patients appearance as he has previously had significant liposuction and the remaining deficit is related to the sub-areolar tissue that should be directly excised. Therefore, the requested suction assisted lipectomy trunk (CPT 15877) does not meet the reconstructive surgery criteria. In sum, the requested mastectomy is medically necessary to correct a complication of a previously medically necessary surgery.  However, suction assisted lipectomy trunk (CPT 15877) is not medically necessary or reconstructive in nature for treatment of the patients gynecomastia. 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 partially overturned.  Credentials/Qualifications: The reviewer is board certified in plastic and reconstructive 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

A 35-year-old male enrollee has requested continued annual examination/evaluation with a retina specialist (the same specialist who performed the original surgery five years ago) for treatment of his detached retina. Findings:  The physician reviewer found that annual eye examinations are medically indicated for this patient. However, it is not medically necessary that the original surgeon performs these evaluations. The Health Plan has offered follow-up treatment with in-network providers. An in-network ophthalmologist should be appropriately qualified to perform a thorough dilated retinal examination. This is within the standard of care of board certified ophthalmologists. There is no evidence that this patients scleral buckle will be rejected. This would be a rare event, particularly after several years without problems. If there are future retinal issues, a referral back to the original retina specialist would be indicated. However, at this time, the patient can be appropriately followed with annual examination/evaluation performed by an in-network ophthalmologist.
Appeal type: Medical Necessity
Decision: Overturned

The patient has requested authorization and coverage for a Monovisc injection in the right knee. Evidence from systematic reviews and randomized controlled trials indicate that although viscosupplementation may relieve knee pain in some patients with osteoarthritis, data has not established which patients will benefit. Guidelines from the American Academy of Orthopedic Surgeons (AAOS) indicate that the data on safety and efficacy of viscosupplementation remain inconclusive. As such, the AAOS does not currently recommend viscosupplementation as standard treatment for osteoarthritis of the knees. Viscosupplementation is reserved for patients with a history of lasting benefit from prior injections and in cases where the remaining options are limited. In this case, the patient has osteoarthritis of the right knee. Further treatment with Monovisc provided adequate pain and symptomatic relief. Given the patients prior benefit with Monovisc and the lack of alternative treatment options, the requested Monovisc injection in the right knee 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

A 23-year-old female enrollee has requested an MRI for evaluation of her low back pain. Findings:  The physician reviewer found that this patient presented with first-time sudden onset of low back pain.  At the time of presentation, she reported that her pain began two weeks prior. This patient has been evaluated with lumbar spine x-ray, and the results noted mild degenerative disc disease. At this time, the requested MRI is not medically indicated. Conservative therapy, including physical therapy, is appropriate and is standard of care in this clinical scenario.  The submitted documentation does not indicate that the patient has had an adequate trial of conservative therapy. Evaluation with an MRI would be indicated in the event that the patient has continued pain and radiculopathy following conservative management. All told, the requested MRI is not medically indicated for the evaluation of this patient at this time.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 3-year-old female enrollee has requested occupational therapy, speech therapy and a 90 minute consultation per month for treatment of the enrollees autism. Findings:  The physician reviewer found that the American Academy of Neurology (AAN) and Child Neurology Society (CNS) have developed evidence-based guidelines for treatment of autism. These treatment guidelines include occupational therapy and speech therapy as within the standard of care adopted by the medical community. Specifically, these organizations recommend, Immediate and long-term evaluation and monitoring of autistic individuals in addition to treatment using a comprehensive multidisciplinary approach with a variety of professionals including speech pathologists and occupational therapists. All told, the requested therapies are medically necessary for this patient and should be provided. The services should include occupational therapy for one hour per week and speech therapy for two hours per week. In addition, 90 minutes per month of consultation and collaboration of services with parents and other professionals is reasonable and appropriate and should be authorized.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:   An enrollee has requested breast tomosynthesis for the evaluation of her medical condition.  Findings:  Two physician reviewers found that the addition of breast tomosynthesis reduces false positives and increases cancer detection when compared to two-dimensional mammography alone (Ciatto, et al). In addition, Detection rates, including those for invasive and in situ cancers, were 6.1 per 1000 examinations for mammography alone and 8.0 per 1000 examinations for mammography plus tomosynthesis (Skaane, et al). Thus, the addition of tomosynthesis allows better characterization of possible masses, spiculation, and architectural distortion. Given the support in the peer-reviewed literature for the use of tomosynthesis in the routine screening population, the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: Two 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:   All three reviewers are board certified in diagnostic radiology 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

The patient is a 14-year-old female with an extensive history of mental illness who has received mental health treatment since the age of eight years. She has had suicidal thoughts in the past and was admitted to an inpatient psychiatric unit on two previous occasions. It does not appear from the record there has been an actual suicide attempt. The patient was admitted to the residential treatment facility in June 2006 for mood swings and depression. She was evaluated by a psychiatrist and diagnosed with major depressive disorder. The patient was started on the antidepressant medication doxepin, with titration of her dosage during her stay. She showed some improvement in her symptoms and behavior and as of July 2006, according to the notes of her mental health providers, she was not having suicidal/homicidal thoughts and was not actively psychotic. The patient has been compliant with the milieu/group treatment environment to a limited extent.The patients parent has requested authorization for residential treatment services provided in July 2006 and continuing to the present time.  The Health Plan denied the request based upon a determination that these services are not medically necessary.After a detailed and intensive review of the clinical records and correspondence provided for review, it does not appear that the patient is actively psychotic or that she is actively suicidal or homicidal. The progress notes from two different days in July 2006 indicate that she was improving and there was no indication of an imminent risk of harm to self or to others or of active psychosis. There was no documentation of any medical or psychological complications that would require 24-hour observation and/or intervention.  The treatment that the patient received in the residential treatment facility after July 2006 could have been effectively provided at a lower level of care such as a partial hospital program or an intensive outpatient program. The clinical record does not support the patients need for continued stay at the residential treatment level of care from July 2006 onward.  Therefore, I have determined the requested services are not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.