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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for biofeedback (CPT code 90911). Urinary incontinence is a medical condition that significantly reduces quality of life. Nonsurgical therapy for urinary incontinence is recommended by specialists in urogynecology. Effective first-line treatment options supported in the medical literature include biofeedback techniques. Biofeedback has been shown to reduce symptoms and help patients avoid surgical interventions. In this case, the patient has reported improved symptoms with pelvic floor physical therapy. The addition of biofeedback to pelvic floor physical therapy is likely to provide this patient with even more effective relief of her symptoms. All told, biofeedback (CPT code 90911) is likely to be more beneficial for treatment of this patients medical condition than any available standard therapy.Findings:  Three physician reviewers found that biofeedback (CPT code 90911) is likely to be more beneficial for treatment of this patients medical condition than any available standard therapy.Final Result: The reviewers determined that the biofeedback (CPT code 90911) is likely to be more beneficial for treatment of this patients medical condition than any available standard therapy.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in obstetrics and gynecology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 19-year-old female enrollee has requested for continued psychiatric inpatient care services for treatment of her bipolar disorder.  Findings:  The physician reviewer found that the patient was reported to be at high-risk for self harm given her depressed mood, impulsivity, and recent suicidal ideations with concrete plan and gesture. The medical literature, a patient requires 24-hour inpatient psychiatric treatment when she cannot perform self care or is suspected of being a danger to her self or others. In this instance, the patient was appropriately determined to be unable to function outside of a hospitalized setting. As concluded by Schramm and colleagues, An inpatient treatment program with both brief and intensive psychotherapy plus pharmacotherapy is superior to standard treatment.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for gastric bypass surgery. The Health Plan has denied this request indicating that the requested services are not medically necessary for treatment of the patients obesity. The submitted documentation does not support the medical necessity of the requested services. The records do not document an anatomic complication present for this patient. After a long period of time, dilation and stretching of both the gastric pouch and stoma can occur. Pouch and stoma reduction, whether operative (laparoscopic or open) or endoscopic, has not been shown to have durable efficacy or weight outcomes in any high-grade study. The documentation does not support that this patient had ongoing dietary or behavioral follow-up. The notes do not document a technical complication that would require revision of the patients previous gastric bypass surgery. Therefore, the requested gastric bypass surgery is not medically necessary for the treatment of the 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 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

The enrollee has Hashimotos thyroiditis and has been treated with thyroid therapy in another country. She is requesting authorization and coverage for the requested medication, levothyroxine 50mcg every Monday through Thursday and levothyroxine 75mcg every Friday through Sunday. She is also requesting authorization and coverage for the requested medication, metformin 500 mg daily. She reports an abnormal ultrasound performed in this country, which showed an autoimmune thyroiditis with new focal changes in the left lobe. An ultrasound showed a left thyroid nodule, which was determined by an endocrinologist to be without concerning features or lymphadenopathy, with no indication for fine needle aspiration based on the size or appearance of the lesion. The enrollee also indicates she has been treated for over 30 years with metformin for insulin resistance and is requesting a prescription for metformin. She is having a problem with breast-feeding and milk production has decreased. The endocrinologist indicates endocrine society recommendations remain unchanged at this time and there is no indication for use of metformin in a diagnosis of polycystic ovarian syndrome unless frank diabetes mellitus or pre-diabetes mellitus, with high risk of progression to overt diabetes mellitus, is present. The medical literature indicates levothyroxine is prescribed for hypothyroidism as a replacement therapy in primary, secondary, and tertiary congenital or acquired hypothyroidism.  The record indicates the enrollees report of a diagnosis of thyroiditis and treatment for the past 15 years with thyroid therapy in her home country. The enrollees most recent thyroid function tests were normal. Therefore, it would not be appropriate to discontinue treatment as the two different doses of levothyroxine are keeping the enrollees levels at goal.  The medical literature indicates metformin is prescribed as an adjunct to diet and exercise to improve glycemic control in adults and children with a diagnosis of type two diabetes mellitus.  The record indicates the enrollee was previously diagnosed with glucose intolerance. She has utilized metformin for over 30 years. As the enrollee has utilized the medication with benefit and due to the enrollees glucose intolerance, the requested medication is appropriate.Final Result: The reviewer determined that the requested services are medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in endocrinology, diabetes and metabolism 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for facial feminization surgeries (CPT codes 21179, 15824, 30410, 30520, 15828, 40652, and 20926). The World Professional Association for Transgender Health (WPATH) Standards of Care (SOC) acknowledges that for certain patients, an intervention like a reduction rhinoplasty can have a radical and permanent effect on their quality of life, and therefore is much more medically necessary than for somebody without gender dysphoria. WPATHs SOC further states that [a]lthough [facial feminization procedures] are generally labeled purely aesthetic, these [procedures] in an individual with severe gender dysphoria can be considered medically necessary, depending on the unique clinical situation of a patients condition and life situation. This patient has a history of gender dysphoria and has been living as a female for more than 20 years. She underwent breast augmentation and vaginoplasty, both without complication. She has been using hormones. Her treating physician explains that although the patients gender dysphoria has improved with hormone therapy, she continues to experience symptoms. Her mental health provider reports that the patient experiences discrimination due to her masculine facial features, and that she is fearful of violence because of her appearance; these facts, in turn, contribute to her gender-related anxiety and depression. Both providers indicate that the patient has been vetted for surgery and is physically and psychologically prepared for the procedure. Her providers contend that this surgery can alleviate the patients gender dysphoria and related anxiety and depression. In light of this patients unique clinical presentation, the requested facial feminization surgeries are supported by the WPATH as medically necessary for treatment of this patients gender dysphoria. 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 emergency medicine with expertise in transgender 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 19-year-old female enrollee has requested for adult psychiatric residential treatment for treatment of her self-injury, mood disorder and history of bulimia disorder.  Findings:  The physician reviewer found that review of the physician progress notes demonstrates the patient had improved and had no immediate safety issues.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for residential treatment center (RTC) services. Per the American Society of Addiction Medicine (ASAM) criteria, this patient met Level 3.5 criteria for clinically managed high-intensity residential services. ASAM criteria focuses on six dimensions to determine the appropriate level of care, which includes: (1) intoxication and withdrawal potential; (2) biomedical conditions; (3) emotional, behavioral and cognitive conditions; (4) readiness to change; (5) relapse, continued use, or continued problem potential; and (6) recovery environment. For dimension 1, the provider noted that the patient had a CIWA score of 13, and he was treated for alcohol withdrawal with lorazepam. The patients COWS score was 11, which was managed with suboxone. This supports that the patients conditions were moderately severe. For dimension 2, the patient has a history of chronic low back pain, which contributed to his use of oxycodone for pain relief. The patient is also noted to have OSA treated with CPAP. These problems were stable during RTC admission, but pain interfered with his recovery. The patients OSA is concerning given his ongoing usage of alcohol and opioids. Dimension 3 is satisfied as the patient has diagnoses of PTSD, depression, and GAD. The patient complained of severe anxiety, psychomotor agitation, restlessness, and poor sleep. He indicated that he used substances to manage his psychiatric symptoms. The patient demonstrated difficulty controlling his use and poor impulse control. He had significant functional deficits. For dimension 4, the patient minimized his substance use. He attributed his substance use to external factors such as trauma, marital stress, and family dynamics. Dimension 5 was met, as the patient continued to use opiates and other substances despite assisted outpatient treatment with suboxone. He reported distressing psychiatric symptoms that resulted in overwhelming urges to use oxycodone. The patient would have continued to abuse substances without 24-hour monitoring and structure. For dimension 6, the patient had a high level of tension in his home due to his addictions. The patients social network was comprised of others who used alcohol and other substances. Given these findings, the RTC services were medically necessary for treatment of this patient.Final Result: The reviewer determined that the services at issue were 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 with expertise 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

The parent of a six-month-old female enrollee has requested authorization and coverage for an extensive development assessment.  Findings:  The physician reviewer found that infants born prematurely and those born with extremely low birth weight are at risk for a number of difficulties, including nutrition and growth problems, cerebral palsy and other motor difficulties, neurodevelopmental disabilities, behavioral problems, and sensory impairments.  These children have more language delay, visual-perceptual problems, and problems with attention and behavior.  As noted by Merenstein and Gardner, parents of neonatal intensive care unit infants should be offered comprehensive, coordinated, developmentally based, family-oriented follow-up for their child through infancy and childhood.  In their review of the effectiveness of early developmental intervention post discharge from hospital for preterm infants, Spittle and colleagues concluded that early intervention programs for preterm infants have a positive influence on cognitive outcomes in the short-term and medium-term. In many centers, early developmental follow-up is the standard of care.  All told, the requested extensive development assessment is medically indicated for the evaluation of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for lumbar fusion and lumbar total disc arthroplasty for treatment of the enrollee, who has been diagnosed with degenerative disc disease of the lumbar spine. Findings:  The physician reviewer found that The current medical evidence fails to demonstrate the medical necessity of the requested services. Resnick and colleagues documented that low level evidence did not demonstrate an added benefit of fusion for patients with degenerative disc disease and stenosis without spondylolisthesis. The authors concluded that in the absence of deformity or instability, the inclusion of a fusion was not recommended. Lackey and colleagues conducted a systematic review and meta-analysis of outcomes in hybrid constructs for multilevel lumbar degenerative disc disease. The authors stated that it could not be concluded that a hybrid construct is superior to multilevel lumbar fusion or total disc arthroplasty based on this meta-analysis. The results highlighted the need for further prospective studies to delineate best practice in the management of degenerative disc disease of the lumbar spine. This patient presents with progressively worsening low back pain radiating into the right lower extremity. He is status post two prior discectomy surgeries, one at L4-L5 and one at L5-S1. Clinical examination findings documented motor deficit consistent with degenerative disc disease at the L5-S1 level. He had been diagnosed with L4-S1 spondylosis. The current medical evidence does not support single-level artificial disc replacement in the setting of multilevel lumbar degenerative disc disease. In addition, the proposed disc replacement adjacent to a fused spinal segment would represent a hybrid-type complex/construct, of which there is a lack of significant long-term large volume medical literature studies at large. There is a lack of compelling rationale presented to support the medical necessity of the requested hybrid procedure for this patient. Therefore, the requested lumbar fusion and lumbar total disc arthroplasty is not medically necessary for 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 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: An enrollee has requested surgery of the upper part of the throat for treatment of the enrollees medical condition.  Findings: The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  This patient has been diagnosed with mild obstructive sleep apnea as well as nasal congestion.  Physical examination revealed septal deviation, turbinate hypertrophy, redundant soft palate and elongated uvula.  Polysomnography demonstrated an AHI of 6.0 and oxygen saturation nadir of 73%.  Nasonex has been used for nasal congestion.  The records do not document that prior treatment has been instituted for sleep apnea.  CPT code 30465 is for repair of vestibular stenosis, which is most commonly done with placement of spreader grafts.  In this patients case, there is no documentation on physical examination to support the presence of nasal vestibular stenosis.  The provider has also recommended uvulopalatopharyngoplasty and tonsillectomy.  As standard of care, uvulopalatopharyngoplasty and tonsillectomy are surgical procedures that come under consideration for patients who have been diagnosed as having obstructive sleep apnea and have failed a trial of CPAP therapy.  The records do not indicate a CPAP trial in this patients case.  There is a lack of support for the requested services in this patients case.  In sum, the requested surgery of the upper part of the throat is not medically indicated 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 physician reviewer is board certified in otolaryngology 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 has requested authorization and coverage for gabapentin 600 mg five times per day and Norco 10-325 mg five times per day. The Federation of State Medical Boards (FSMB) guidelines noted that, continuation, modification or termination of opioid therapy for pain is contingent on the clinicians evaluation of (1) evidence of the patients progress toward treatment objectives and (2) the absence of substantial risks or adverse events, such as signs of substance use disorder and/or diversion. The FSMB opined that dosage should be maintained as low as possible and continue[d] only if clear and objective outcomes are being met. The Centers for Disease Control and Prevention (CDC) guidelines state that providers should evaluate benefits and harms of continued therapy with patients every three months or more frequently. If benefits do not outweigh harms of continued opioid therapy, clinicians should optimize other therapies and work with patients to taper opioids to lower dosages or to taper and discontinue opioids. In this case, the patient has a diagnosis of chronic back pain with radiculopathy. She is unable to tolerate non-steroidal anti-inflammatory drugs (NSAIDs) due to a history of cardiomyopathy. A recent urine drug screen was positive for THC and a repeat urine drug screen is pending. The patient endorses use of cannabis for insomnia. Based on the current guidelines from the CDC and FSMB, the risks of combining opioid therapy with cannabis outweigh the potential benefit of chronic opioid therapy. Based on the available records for review and the guidelines regarding prescribing opioids for non-cancer pain, Norco is not medically necessary for treatment of this patient. However, the patients diagnosis of chronic low back pain with radiculopathy and intolerance to NSAIDs supports treatment with gabapentin. Consistent with the available data, gabapentin 1200 mg three times per day is medically necessary to treat the patients chronic back pain with radiculopathy, while Norco 10-325 mg three times per day is not medically necessary for treatment of this patient. Final Result: The reviewer determined that a portion of the requested regimen is 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 anesthesiology with subspecialty certification in pain management 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 70-year-old male enrollee has requested for a consultation for no needles technique for cataract surgery for treatment of her condition. Findings:  The physician reviewer found that the patient desires to have his surgery performed using the small incision, topical anesthesia technique. This technique has become the standard of care for the past ten to fifteen years because of decreased complication rates, faster recovery and diminished pain.