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

A female enrollee requested a positron emission tomography (PET) scan for medical evaluation of her melanoma.  Findings:  Two physician reviewers found that current medical evidence supports up to three PET scans for all solid tumors. The Centers of Medicare and Medicaid Services decision memo recognized melanoma as a valid indication in cases where there is suspicion of recurrence to regional lymph nodes such as this case. The ability of PET scans to analyze the physiologic properties of masses or nodes provides more information than standard imaging techniques. All told, a PET scan was likely to have been of greater benefit than other available modalities for evaluating this patient.
Appeal type: Experimental/Investigational
Decision: Overturned

A 52-year-old male has requested coverage for past transcranial magnetic stimulation for treatment of his major depressive disorder.   Findings:  Two physician reviewers found that the patient has a history of anxiety.  His provider noted that following several years of unsuccessful treatment for anxiety, the patient began to experience periods of severe depression.  The provider noted that the patient has tried multiple medications, without success.  These medications included Neurontin, Effexor, Emsam, Lamictal, Lexapro, lithium, Parnate, Nardil, Zoloft, Seroquel, Paxil, Serzone, Trileptal, Wellbutrin, Remeron, Cymbalta, Prozac, Depakote, Luvox, Pamelor, Anafranil, Celexa, Buspar, and Elavil.  Per the submitted documentation, he experienced moderate benefit from electroconvulsive therapy.  In this patients case, the transcranial magnetic stimulation provided was likely to have been more efficacious than other treatment modalities.  The current medical evidence supports the services at issue in this clinical setting.  The American Psychiatric Association guidelines indicate that transcranial magnetic stimulation is an appropriate acute phase treatment option for patients who do not response adequately to medication therapy.  This patient has received multiple evidence-based treatments, including medications and electroconvulsive therapy.  In this clinical setting, transcranial magnetic stimulation therapy was likely to have been of greater benefit than other treatment modalities.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a morbidly obese male of 59 years with a body mass index (BMI) of 41.8. His comorbidities include diabetes mellitus, hypertension and joint pain. The patient has completed a psychological evaluation with a positive recommendation for the surgery. It appears he has attempted weight loss with both supervised and unsupervised programs. The Health Plan has denied authorization for bariatric surgery stating there is incomplete documentation of the patients participation in a six-month supervised weight loss program, and therefore medical necessity for the surgery has not been established.With a BMI of 41.8 and comorbid conditions such as diabetes mellitus, hypertension and joint pain, the patient meets nationally accepted medical necessity criteria for consideration of weight loss surgery. It is highly likely that gastric bypass surgery will be beneficial for this patient. Furthermore, the patient does not require further dietary workup prior to undergoing weight loss surgery. There is no scientific evidence demonstrating that structured diet or exercise plans have been successful in the treatment of the obese. In fact, the Swedish obesity study identifies that even though there may be reduction or resolution of some symptoms with diet and exercise, surgery has the best long-term outcome for the obese. Based upon the information set forth above, I have determined that the requested surgery is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

A 36-year-old female enrollee has requested duodenal switch bariatric surgery without documentation of participation in a 12-week weight loss program and/or 10% body weight loss for treatment of her obesity.  Findings:  The physician reviewer found that although this patient is morbidly obese and may be a candidate for bariatric surgery, all patients should have made reasonable efforts to lose weight and complete a multidisciplinary evaluation that includes dietary and behavioral evaluations. Bariatric surgery requires careful patient evaluation and the weight loss program recommended by this patients surgeon appears to be multidisciplinary (behavioral and dietary) in nature as part of pre-operative weight loss. As noted by Elder and Wolfe in the peer reviewed literature, Bariatric surgery patients undergo many dramatic lifestyle changes, and comprehensive pre-surgical screening conducted by a multidisciplinary team is important to prepare patients for the numerous changes necessary for successful outcome. Further, the authors stated that, comprehensive pre-surgical screening can aid the treatment team in identifying patients who would benefit from additional services prior to or following surgery. Consistent with these recommendations, the National Institutes of Health (NIH) consensus guidelines require documentation of failed weight loss attempts, which was not submitted with this patients records. Thus, although the patient has indicated that she has undergone adequate weight loss programs, without documentation of supervised efforts at pre-surgical weight loss, the medical necessity of the requested referral has not been established at this time.
Appeal type: Medical Necessity
Decision: Upheld

A 47-year-old female enrollee requested authorization and coverage of a total hip replacement using the anterior approach.  The Health Plan denied the enrollees request indicating that the requested treatment 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 services are not medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for nerve stimulation services for treatment of the enrollees urinary frequency and urgency.  Findings:  Three physician reviewers found that this patient is quite symptomatic with urgency and frequency. She failed multimodal therapy. Percutaneous tibial nerve stimulation is considered to be an appropriate salvage therapy for patients with intractable lower urinary tract symptoms according to the current guidelines. The duration of the treatment and the frequency is not established. It is generally agreed upon that the patient should at least have six treatments to decide whether this is effective form of treatment. Final Result: two of three reviewers determined that the services at issue were likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: All three reviewers are board certified in urology 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 58-year-old male enrollee has requested binge eating disorder (BED) group for treatment of his behavioral health conditions.   Findings:  The physician reviewer found that the requested services are not medically necessary for treatment of the patients medical condition. According to the documentation submitted for review, this patient has been attending binge eating disorder group for a couple of years without much improvement. Given the patients primary diagnosis is narcissistic personality disorder, it is not medically necessary for him to be attending a binge eating group. Moreover, it is likely that the reason the patient is not progressing in the binge eating group is that it is not treating his primary diagnosis. Therefore, it is not medically indicated for him to continue receiving treatment in the BED group. The treatment team has provided a reasonable alternative treatment to this patient, to continue individual therapy with a new therapist. Based on the medical literature cited above and the documentation submitted for review, the requested services are not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Orthovisc injection for the right knee for treatment of the enrollees knee pain. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services. The current peer-reviewed literature generally supports repeat hyaluronic acid injections, such as Orthovisc, for the treatment of osteoarthritis of the knee if there is documented significant improvement for six months or more, but do not support the use of these injections in patellofemoral osteoarthritis. A review of the treating providers report does not evidence six months of significant improvement following the prior Orthovisc injections, as a corticosteroid injection was performed within four months. Additionally, there is no evidence of significant osteoarthritis outside of the patellofemoral compartment. There is a lack of support for the requested services in this clinical setting. 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: Overturned

A 35-year-old female enrollee has requested bilateral reduction mammoplasty and abdominoplasty for treatment of her back, neck and shoulder pain. Findings:  The physician reviewer found that the patient has generalized skin laxity consistent with her history of massive weight loss. Correction of skin laxity following massive weight loss is generally considered cosmetic in the absence of clear and compelling documentation of specific signs and symptoms that 1) are clearly related to the excess skin 2) are health threatening or cause significant functional disability and 3) have failed to improve despite reasonable attempts at conservative therapy.  A reasonable standard for evaluating the medical necessity of potentially cosmetic surgery is whether the submitted records include convincing and confirmatory evidence of a chronic functional problem that has failed reasonable attempts at conservative therapy.  The submitted records do not establish medical necessity for the proposed abdominoplasty.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for gene mutation blood test. Findings:  Three physician reviewers found that the evidence suggests that the MTHFR genotype plays a minor and negligible role in predicting risk of thrombosis. There is a lack of evidence supporting the utility of screening for MTHFR mutations in the management of patients, or family members of patients, with a history of thrombosis. The medical evidence does not support the services at issue in this patients case. In sum, the superior effectiveness of gene mutation blood test has not been established.Final Result: The reviewers determined that the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in internal medicine 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

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for weekly individual therapy visits and monthly psychiatric visits. The medical records indicate that the patient has been receiving therapy on outpatient basis at an interval of every two weeks for the past six to seven months. Clinical recommendations from the patients provider include continuation of therapy every two weeks. The intervals of psychotherapy are defined by patient symptom presentation and progress in treatment. The progress notes reflect that the patient is progressing in treatment. In addition, the patient has not been demonstrating severe symptoms such as suicidal or homicidal ideation, psychosis, or aggressive behavior. Therefore, weekly individual therapy visits are not supported by the clinical information provided for review. Further, the patient appears stable on her current medication regimen. The most recent progress notes indicate the patient could follow-up with her psychiatrist every four to six weeks. Thus, the requested monthly psychiatric visits are not medically necessary for treatment of this patient. All told, the requested weekly individual therapy visits and monthly psychiatric visits are 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 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 12-year-old male enrollee has requested coverage for continued applied behavior analysis (ABA) therapy (15 hours per week of code H2019, 6 hours per month of code H0032, and 3 hours per month of code H2012) from a specific date and forward.  Findings:  The physician reviewer found that autism is a complex neurological disorder with characteristic deficits in speech and language and social interaction.  Deficits in fine and gross motor skills and processing of sensory and motor information are also common.  There are likely a multitude of etiologies, with clinical symptoms being the final common denominator.  Many approaches have been used to facilitate development of adequate communication and interpersonal skills in these children.  Typically, children on the autistic spectrum require interventions in multiple areas, including speech therapy, occupational therapy, and behavioral therapy.  Applied behavior analysis (ABA) is a behavioral approach with a longstanding history of application with children on the autistic spectrum.  ABA programming utilizes scientifically validated methods that are incorporated into a comprehensive individualized plan for the child with autism.  In the study by Eikeseth and colleagues comparing children who received intensive behavioral treatment to those who received a more eclectic treatment modality, the behavioral treatment group exhibited larger increases in IQ and adaptive functioning, as well as less aberrant behaviors and social problems, than did the other group.  Behavioral approaches are considered to be first-line treatment for autistic spectrum disorders, along with speech and language therapy.  There is a growing body of evidence in support of ABA therapy, demonstrating improvement in development and intellectual performance in young children with autism.  The results regarding individuals who are three years of age or younger are particularly compelling.  However, ABA therapy has been used effectively in many patient populations, including adolescents, for over 40 years.  According to Foxx, it is the primary method of treatment for children and adolescents on the autistic spectrum with aberrant behavior.  All told, continued ABA therapy (15 hours per week of code H2019, 6 hours per month of code H0032, and 3 hours per month of code H2012) from the requested date and forward was and is medically indicated.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Xeljanz 5 mg BID (twice daily). Alopecia areata is a chronic immunological disorder characterized by round or oval patches of non-scarring hair loss. Alopecia universalis is a form of alopecia areata that includes eyebrows, eyelashes and facial hair. Treatment focuses on the regrowth of hair. Onset of alopecia areata can have a negative effect on a patients self-esteem, body image, and self-confidence. The experience of alopecia is psychologically harmful and can lead to personal and social problems. Xeljanz is an oral Janus kinase (JAK) 1/3 inhibitor that has been U.S. Food and Drug Administration (FDA) approved for the treatment of moderate to severe rheumatoid arthritis. Studies have also evaluated Xeljanz for treatment of psoriasis, inflammatory bowel disease, and other immunological diseases. Several recent reports in the literature provide evidence for the effectiveness of Xeljanz in the treatment of alopecia areata (Jabbari, et al.; Anzengruber, et al.; Xing, et al.). This patient presents with alopecia areata that has been resistant to multiple standard medical therapies. Given the support in the medical literature, Xeljanz 5 mg BID (twice daily) is medically necessary for 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: An enrollee has requested reimbursement for the hospital stay. In this case, the hospital stay is supported as medically necessary for treatment of this patients medical condition. The patient was at risk for recurrence of UTI due to her prior ureteral reimplantation and history or urinary tract abnormalities. She had started to respond to antibiotic, but had right flank tenderness on physical examination and required Norco for control of dull flank pain at 7/10. She had just transitioned to oral Levaquin therapy. For these reasons, the hospital stay is supported as medically necessary for the treatment of the patients urinary tract infection and pyelonephritis.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 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for rimabotulinum toxin B injections for treatment of the enrollees chronic myofascial pain. Findings:  The physician reviewer found that the requested services are not medically necessary for treatment of the patients medical condition. The patient has chronic nonmalignant pain with a diagnosis of thoracic myofascial pain. Rimabotulinum toxin B injections are not recommended for the treatment of myofascial pain. Indications for the use of rimabotulinum toxin B injections include the treatment of cervical dystonia and migraine prophylaxis and for the treatment of spasticity due to an upper motor neuron condition such as a spinal cord injury or stroke or when treating sialorrhea. Use of rimabotulinum toxin B injections in this clinical setting could potentially produce weakening of the spinal muscles and a potential worsening of the spinal condition. Based on the peer-reviewed literature and clinical documentation, rimabotulinum toxin B injections are not medically necessary for the treatment of the patients medical condition. 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 physical medicine and rehabilitation 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 patient has requested authorization and coverage for (1) Otezla 28-day starter pack, and (2) Otezla 30 mg tablets (60 tablets/30 days). Findings:  The physician reviewer found that Otezla (generic name apremilast) is a phosphodiesterase 4 inhibitor. A review of studies suggests that this medication is effective for the treatment of moderate to severe psoriasis. The American Academy of Dermatology guidelines state that apremilast is recommended for the treatment of moderate to severe psoriasis. In this case, the patient presented with a two-year history of dry flaking skin.  On examination, it was estimated to cover approximately 15% BSA. He was started on apremilast. On follow-up one month later, it was noted that the patient had not significantly improved, and he was started on a higher potency steroid. Subsequent follow-up found that the patient had improved on the combination. There is sufficient support for the requested medication in this clinical setting. Therefore, (1) Otezla 28-day starter pack, and (2) Otezla 30 mg tablets  (60 tablets/30 days) are medically indicated 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.