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

A 63-year-old male enrollee has requested transcranial magnetic stimulation (TMS) for treatment of his major depressive disorder.  Findings:  The physician reviewer found that review of the submitted documentation demonstrates the medical necessity of the requested therapy. The peer-reviewed literature continues to demonstrate positivism for TMS while researchers have identified a possible mechanism for the antidepressant effect of TMS (Ueyama et al). Further, TMS has been cleared by the U.S. Food and Drug Administration (FDA) and endorsed by the American Psychiatric Association (APA) in its current clinical practice guideline for the treatment of individuals with depression. In this case, the patient is enduring an acute major depressive episode that is causing significant morbidity and functional impairment. Based on the medical records provided, endorsement from the APA and the expanding peer-reviewed literature base, TMS is appropriate to treat this patients depressive symptoms and consistent with good medical practice. In sum, TMS is a safe and reasonable intervention to treat this patients major depressive disorder at this particular stage of illness and therefore, medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

A 46-year-old female enrollee requested authorization and coverage for gastric bypass surgery. The Health Plan denied the request indicating that the requested procedure is not medically necessary for treatment of the enrollees morbid obesity.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plans denial on the basis that the requested procedure is medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for an Euflexxa injection series for the right knee. Per the medical literature, although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. The current evidence is limited, and guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate that the evidence is not conclusive. In light of the foregoing, viscosupplementation can only be recommended in individuals with a history of lasting benefit from prior injections, and in carefully selected cases where everything else has been tried, and the options are limited. In this case, the patient has tried and failed other conservative treatments, with the alternative being a total knee arthroplasty. Given the patients limited options and based on the current medical literature, the requested services are medically indicated. Therefore, an Euflexxa injection series for the right knee is medically necessary for the 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: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Xeomin (incobotulinumtoxin A) injections. Findings: Cervical dystonia is a movement disorder clinically characterized by involuntary contractions of cervical muscles, which cause abnormal head movements and postures, often associated with head tremor and chronic pain. Classifications of cervical dystonia include torticollis, laterocollis, anterocollis, and retrocollis or a combination of these movements. Per the American Academy of Neurology (AAN) practice guidelines, Xeomin  is recommended as first-line treatment for cervical dystonia. The U.S. Food and Drug Administration (FDA) has approved Xeomin for the treatment of cervical dystonia. Per the AAN guidelines, Xeomin and onabotulinumtoxinA should be considered as options for the treatment of cervical dystonia. In this case, the patient has cervical dystonia with spasmodic torticollis. The patient has reportedly failed treatment with methocarbamol, Baclofen, Carisoprodol, and cyclobenzaprine. However, the patient experienced symptomatic improvement with Xeomin. Given these findings, the requested Xeomin (incobotulinumtoxinA) injections are 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 neurology 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 enrollee requested coverage for Otezla 30 mg tablets for plaque type psoriasis. The records indicate the enrollee has moderate to severe plaque type psoriasis primarily with psoriasis on the hands, palms, fingers and nails, as well as other areasof the body.  She has tried and failed topical corticosteroids.  She has been using Otezla with improvement.  The medical literature indicates biologic agents are considered the gold standard for moderate to severe psoriasis due to their favorable safety profiles and excellent efficacy.  Treatment recommendations depend on severity of disease and can include topical therapy alone or in combination with phototherapy and/or traditional non-biologic systemic therapy. The patient has no noted contradictions to taking methotrexate, cyclosporine, acitretin, Enbrel, Humira, or Cosentyx, which have been shown to have favorable safety profiles and efficacy. In addition, there is no medical reason noted as to why phototherapy was not tried.  Final Result: The reviewer determined that the service at issue was not medically necessary for treatment of the patients condition. Credentials/Qualifications: The physician 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 similar medical condition.
Appeal type: Urgent Care
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for medical services. The Health Plan has denied this request indicating the enrollee did not receive emergency medical services. Findings:  The physician reviewer found that the medical services provided were not necessary for treatment of an emergency medical condition. In this case, there was no emergent medical condition noted in the records submitted for review. The patients treatment received on the dates in dispute were necessary and appropriate, however there is a lack of documentation demonstrating the services were for emergency care. Therefore, the services provided were not considered emergency medical services. Thus, the patient did not receive emergency medical services on the dates of service at issue. Final Result: The reviewer determined that the patient did not receive emergency medical services on the dates of service at issue. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in infectious 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

A 51-year-old male enrollee has for revisional bariatric surgery (RNY) for treatment of his morbid obesity. Findings:  The physician reviewer found that there is no indication that the weight regain was the result of a medical or surgical complication.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for bilevel positive airway pressure (BiPAP) machine and its associated supplies. Applying the practice guidelines from the American Academy of Sleep Medicine (AASM), this patient meets the criteria to establish the medical necessity of the BiPAP and related accessories for treatment of her moderate obstructive sleep apnea (OSA). The AASM state that for appropriate and effective management of patients with OSA treated with positive airway pressure: (1) Treatment of OSA with PAP therapy should be based on a diagnosis of OSA established using objective sleep apnea testing. (2) Adequate follow-up, including troubleshooting and monitoring of objective efficacy and usage data to ensure adequate treatment and adherence, should occur following PAP therapy initiation and during treatment of OSA. The records provided for review document that this patient underwent objective sleep apnea testing, which demonstrated findings consistent with moderate OSA. In addition, the patient has followed up with her provider and has been compliant with BiPAP for treatment of her OSA. Furthermore, the provider documented that the patient has experienced benefit with use of the BiPAP machine. Given these findings, the BiPAP machine and its associated supplies were and are medically necessary for treatment of this patient. Final Result: The reviewer determined that the equipment at issue was and 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 expertise in sleep 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested Gamma Knife surgery for treatment of her medical condition.  Findings: The physician reviewer found that stereotactic radiosurgery (SRS) implies the use of technologies which improve targeting accuracy, and allow for high dose, single fraction radiation delivery. Generally, a three-dimensional coordinate system is used to more accurately localize the target(s). CyberKnife is different than Gamma Knife. CyberKnife is a delivery system which allows for SRS, using real time monitoring of fiducials or bony anatomy, coupled with robotically controlled tracking of these fiducials. With CyberKnife, the patient is immobilized in a less rigid frameless system. There is no known clinical benefit of any SRS system over another. CyberKnife has the ability to treat patients without a neurosurgical frame, therefore CyberKnife surgery is the preferred procedure in this clinical setting. Accordingly, the request for Gamma Knife surgery has not been established as medically necessary for 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 physician reviewer is board certified in radiation oncology 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 parent of an enrollee has requested reimbursement and prospective authorization and coverage for 38 hours per week of direct applied behavioral analysis (ABA) therapy (Code H2019), 10 hours per month of supervision (Code H0032) and two hours per week of parent training (Code S5110) for treatment of his autism. Findings:  The physician reviewer found that The request for 38 hours per week of direct ABA therapy (Code H2019), 10 hours per month of supervision (Code H0032) and two hours per week of parent training (Code S5110) have not been established as medically necessary for treatment of the patients autism. ABA therapy is a well-established effective treatment for the behavioral features of autism spectrum disorder, but the optimal intensity and duration have not been established. Goals of therapy are directed towards generalization of mastered skills. According to the documentation submitted for review, the patient is not exhibiting aggressive behavior, and his self-injurious behavior in the form of ear pulling is mild. Aside from an increase in behaviors when he was undergoing assessment for high school placement, the patient has had a decrease in verbal outbursts reported, and behavioral and verbal stereotypies have remained constant. The Health Plans authorized amount of ABA therapy is medically reasonable and appropriate for this patient. Final Result: The reviewer determined that the services at issue were not and 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 pediatrics with sub-specialty certification in developmental-behavioral pediatrics 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 enrollee is requesting reimbursement for residential treatment center services. He has a history of anxiety, depression, alcohol and substance abuse and was admitted to residential care for detoxification. He has a history of detox/residential treatment; twice as an adolescent and recently as an adult. Progress notes from discharge show the enrollee with appropriate affect, an angry and irritable mood, with fair judgment, and no suicidal/homicidal ideation. A physical assessment note documented his appetite as good, with no tremors, headache, or nausea and vomiting.  According to the LOCUS system, for risk of harm, the enrollees score is 2, because he has a history of substance use without significant episodes of potentially harmful behaviors. For functional status, the enrollees score is 3, due to chronic and variably severe deficits in his interpersonal relationships, his ability to engage in socially constructive activities, and his ability to maintain responsibilities. For comorbidity, the enrollees score is 3, due to recent substance use which has had clearly detrimental effects on the presenting disorder, but has been temporarily arrested through the use of a highly structured or protected setting or through other external means. He has ongoing or episodic substance use occurring; despite adverse consequences, with a significant or potentially significant negative impact on the course of any co-existing psychiatric disorder. For recovery environment level of stress, the enrollees score is 3, due to a significant transition causing disruption in life circumstances; such as job loss. He has easy exposure and access to alcohol and drug use. For recovery environment level of support, the enrollees score is 2, because supportive resources are not abundant, but are capable of and willing to provide significant aid in times of need. For treatment and recovery history, the enrollees score is 3, because previous or current treatment did not achieve complete remission of symptoms or optimal control of symptoms. For engagement and recovery status, the enrollees score is 2, because he shows some recognition of his personal role in recovery and accepts some responsibility for it. He demonstrates significant understanding and acceptance of his illness and attempts to understand its effect on function. He has demonstrated willingness to change. He fully participated in groups. The enrollees composite LOCUS score is 18, which correlates with high intensity community-based services. Medical evidence does not support the services at issue in this clinical setting.Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for magnetic resonance imaging (MRI) of the right shoulder. due to a multiplicity of potential etiologies, diagnosis of shoulder impingement syndrome is established by a history and physical examination and may be confirmed with x-rays, ultrasonography, and MRI. The authors further note that while initial treatment is conservative, if symptoms persist, decompressive surgery may be necessary, and that a correct etiologic diagnosis and choice of treatment are essential for a good outcome. In this case, the patient reported right shoulder pain that had been present for approximately four months that was not responsive to conservative measures. The provider diagnosed impingement syndrome and recommended an MRI of the shoulder. In this clinical setting, given that the patients pain has lasted over four months and is unresponsive to conservative treatment, and as x-rays did not show a reason for the pain, confirmation of an accurate diagnosis by an MRI is indicated. Therefore, an MRI of the right shoulder is medically necessary for the evaluation of this patient.Final Result: The reviewer determined that the requested service 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 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for bariatric surgery (CPT code 43775-laparscopy, surgical gastric restrictive procedure, longitudinal gastrectomy (i.e. sleeve gastrectomy)) with two day stay for treatment of the enrollee's morbid obesity and hip pain. Findings:  The physician reviewer found that there is support in the medical literature as well as in the documentation provided for review to support the requested services in this clinical setting. Based on the records, this patient meets the criteria for bariatric surgery from the American Society for Metabolic and Bariatric Surgery (ASMBS) guidelines. The patient is morbidly obese. The patient has failed dietary efforts without success and completed a comprehensive multidisciplinary evaluation that did not reveal any obvious dietary or behavioral barriers to surgery. The patient has obtained medical clearance as well as clinical support for surgery. The patients record supports the presence of comorbid conditions. The patient is not able to undergo treatment of his hip secondary to increased risks of surgery given his high BMI. Therefore, six months of supervised weight loss efforts is not supported by published literature and would delay necessary treatment and care. 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 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 parent of a two-year, eight-month-old female enrollee has requested speech and language therapy for treatment of the enrollees speech delay. Findings:  The physician reviewer found that extensive review of the literature including meta-analysis by Law and colleagues demonstrates the positive effect of speech and language therapy interventions for children with expressive phonological and vocabulary difficulty. Appropriate receptive language skills and symbolic play are associated with resolution of delays. As noted by Feldman and Messick, intervention in the form of speech and language therapy attempts to create an optimal language learning environment which capitalizes on the importance of environmental stimulation in the process of learning language. The authors recommend speech therapy for patients with a delay of greater than 25% and found that approximately 50% of patients who are delayed at 2-years, catch up to their peers by 3-years of age with appropriate treatment. The discussion concluded that patients who participate in speech-language treatment show improvement when compared to patients who did not receive therapy.  Based on the records provided, this patient has a greater than 50% identified delay in expressive speech. Given this patients continued deficits in expressive and receptive language, future services are indicated. All told, the requested speech and language therapy is medically necessary for this patient and should be authorized.