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

A 37-year-old female enrollee has requested a duodenal switch procedure (as opposed to a Roux-en-Y gastric bypass) the for treatment of her morbid obesity. Findings:  The physician reviewer found that the patient meets generally accepted guidelines for bariatric surgery established by the National Institutes of Health. The duodenal switch procedure is an appropriate primary treatment for morbid obesity. It has been approved by the American College of Surgeons, the American Society for Metabolic and Bariatric Surgery, the Society of American Gastrointestinal and Endoscopic Surgeons and Centers for Medicare and Medicaid Services based on scientific data including long-term follow-up of over 10 years. The available scientific literature demonstrates the duodenal switch procedure is more appropriate for this patient than any other weight loss procedure available in this setting. As with any weight loss surgery, appropriate presurgical multidisciplinary evaluation (including dietary evaluation and TSH level) should be obtained prior to proceeding with surgery.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 42-year-old female with a presumptive diagnosis of narcolepsy and symptoms of hypersomnolence. She has been maintained on Provigil for over six years. The patient underwent a sleep study in September 2000, which revealed a mild, non-positional sleep breathing disorder consistent with mild upper airway resistance syndrome. There was no specific evidence of narcolepsy or obstructive sleep apnea. The patients request for authorization of Provigil was denied by the Health Plan citing a lack of medical necessity.The FDA approved indications for Provigil include narcolepsy syndrome, sleepiness due to obstructive sleep apnea and sleepiness due to shift work sleep disorder. Additional off-label uses include the treatment of attention deficit disorder, fatigue associated with chronic diseases, psycho-stimulant abuse, and depressive disorders. None of these indications apply to this patient as she is reportedly being prescribed Provigil for excess daytime sleepiness without an identified etiology; there is no evidence of narcolepsy.  Other treatment modalities including sleep hygiene interventions, increased exercise, and/or dietary modifications are available that might be explored. Additionally, an MSLT was previously recommended, but there is no evidence the testing has been completed. The potential side effects of Provigil are significant and include cardiovascular and psychiatric symptoms. Hence the risks associated with this medication are not outweighed by the patients subjective report of symptom improvement.Based upon the information set forth above, I have determined the requested medication is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting authorization and coverage for epidural injections, CPT code 62323 and CPT code 64483. The enrollee has low back pain and left leg weakness, as well as left shoulder pain and weakness following a rollover motor vehicle accident. The enrollee has had a history of chronic low back pain for a number of years and indicates he used to get epidural injections. In an office visit with his orthopedic surgeon, the record indicates the enrollees back pain has gotten to the point where he now cannot walk any significant distance without a limp and he has trouble sleeping at night. He also noted weakness of the left lower extremity and has difficulty with some bowel and bladder functions. During the visit, interpretation of a magnetic resonance imaging (MRI) scan noted prominent L4-L5 and L5-S1 disk bulges with thecal sac impingement. The record indicates the enrollee works laying tiles and has had epidural injections in the past that enable him to return to work. The enrollee has had chiropractic therapy and physical therapy for greater than four weeks.  The pain is progressive and he has noted some bowel and bladder problems but not total incontinence. The enrollee has lumbar radicular pain, significant neurologic signs and MRI documented disc disease with neuroforaminal stenosis. He meets the standard criteria in the medical literature for an epidural steroid injection.  He has failed conservative therapy. The enrollee has had prior epidural steroid injections after which he was able to return to work. The key goal is the ability to obtain relief and return to work after injections. 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 anesthesiology and 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 similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

The parent of a 7-year-old male enrollee has requested a Kineret (anakinra) injection for treatment of the enrollees systemic onset juvenile idiopathic arthritis.  Findings:  Three physician reviewers found that Kineret (anakinra) is likely to be more effective for this patient than other available treatment options. The patient has systemic onset juvenile idiopathic arthritis manifested by high fever, rash and multiple joint arthritis. The patients symptoms have not been controlled with multiple previously tried agents that include steroids, methotrexate and anti-tumor necrosis factor agents. The patients symptoms were completely controlled and in remission while taking Kineret. The medical literature cited above supports the use of Kineret in this patients disease process as he has been significantly responsive to this medication.  Moreover, if left untreated, this patient will likely not be able to function on a daily basis secondary to severe symptoms and could also experience long term sequelae of this disease to include possible joint destruction and kidney failure. Therefore, the requested medication is likely to be more beneficial than other treatment alternatives in this patients case.
Appeal type: Medical Necessity
Decision: Upheld

An 18-year-old female enrollee has requested psychiatric residential treatment services for treatment of her behavioral health problems.  Findings:  The physician reviewer found that based on the submitted clinical documentation, it appears this patient was admitted to a residential level of care primarily to avoid incarceration at the juvenile hall. Preceding this admission, the patient had had three consecutive residential treatment admissions for a combined stay of 24 months without benefit. There is no evidence that her most recent admission was likely to have therapeutic benefit. Furthermore, the records provided from the most recent admission include no evidence of psychotic behavior or suicidal ideation requiring a 24-hour structured setting.
Appeal type: Medical Necessity
Decision: Upheld

A 43-year-old female enrollee requested authorization and coverage of bilateral blepharoplasty. The Health Plan denied the request indicating that the requested procedure is not medically necessary for treatment of the enrollees bilateral blepharochalasia.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested procedure is not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

The enrollees parent is requesting reimbursement for the final seven hours of neuropsychological testing. The enrollee has social anxiety. His mother reports the enrollees behavioral, social, and communication issues began causing significant problems at home and in school. The enrollee underwent neuropsychological testing. The enrollees psychologist reports the assessment was necessary to his mental and physical health, as it greatly informed treatment options and clarified differential diagnoses. Literature indicates neuropsychological assessments are often used to provide additional information about a variety of developmental disorders. The most common questions concern medical disorders, such as genetic disorders, brain injury, and neurologic concerns such as epilepsy and movement disorders. Disorders such as dyslexia, attention deficit hyperactivity disorder, autism spectrum disorder, and fetal alcohol spectrum disorder are common reasons for referral for assessment. Psychiatric disorders such as obsessive-compulsive disorder, anxiety and depression, are referred for evaluation in order to understand the child's difficulty and to provide recommendations for treatment at home and at school. As a result of the neuropsychological assessment, this enrollee was diagnosed with social anxiety. Depending on the age of the child, level of tolerance and numbers of tests, the assessment may require multiple days.Final Result: The reviewer determined that the requested services were medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested acupuncture services for treatment of her medical condition.  Findings:  The physician reviewer found that while studies on the effects of acupuncture for the treatment of foot pain are limited, there is data supporting the use of acupuncture as an effective modality for those experiencing chronic pain. A paper noted that significant differences in results between true and sham acupuncture, which indicates acupuncture is more than a placebo. In this patients case, review of the submitted clinical documentation demonstrates that the patient has undergone multiple attempts at treatment of her foot pain without benefit. According to the submitted documentation, the patient continues to experience severe symptoms and impairment of her daily activities secondary to her unrelieved foot pain. As such, acupuncture is medically reasonable and appropriate to attempt to manage the patients pain and improve function. Therefore, the requested acupuncture 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 oriental 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for mitral valve repair (MitraClip). Findings:  The physician reviewer found that U.S. Food and Drug Administration (FDA) approved percutaneous mitral valve repair using the MitraClip device for high risk patients with degenerative or other primary mitral valve regurgitation. The COAPT trial evaluated patients with 3-4+ mitral regurgitation who remained symptomatic despite maximally tolerated guideline directed medical therapy (Asch, et al.). The authors found that the patients benefited from MitraClip implantation, regardless of their degree of left ventricle (LV) dysfunction, LV dilatation, pulmonary hypertension or individual mitral regurgitation characteristics. However, the American Heart Association (AHA) and American College of Cardiology (ACC) guidelines for the management of patients with valvular heart disease included the MitraClip with a Class IIb recommendation for severely symptomatic patients with chronic, severe primary mitral regurgitation who have favorable anatomy for the procedure and but have a prohibitive surgical risk because of severe co-morbidities and remain severely symptomatic despite optimal medical therapy. Based on the available documentation, this patients preliminary surgical risk is less than 1%, which is not consistent with a prohibitive surgical risk. Therefore, the requested MitraClip is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Findings:  Two of the three physician reviewers found the requested MitraClip is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewer 1 is board certified in internal medicine with subspecialty certification in cardiovascular disease and is actively practicing. Physician reviewer 2 is board certified in internal medicine with subspecialty certification in cardiology and is actively practicing. Physician reviewer 3 is board certified in internal medicine with subspecialty certifications in cardiovascular disease and clinical cardiac electrophysiology and is 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for AmniSure rupture of membranes (ROM) testing for evaluation of her suspected possible ROM. Findings:  Three physician reviewers found that AmniSure ROM testing has been recommended as an adjunct to standard assessment of pooling, ferning and nitrazine testing of vaginal fluid if these tests are inconclusive. AmniSure is not recommended as a first-line test. The study compared AmniSure with standard methods for diagnosing rupture of fetal membranes. The authors noted false-positive test result rates of 19-30% in patients with clinically intact membranes and symptoms of labor. Given that the patients records do not document that she underwent standard testing with pooling, ferning and nitrazine testing of vaginal fluid, the AmniSure ROM testing performed on 7/11/16 was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: The reviewers determined that the testing at issue was 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: Reviewers 1, 2, and 3 are board certified in obstetrics and gynecology and is 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

This patient is a 49-year-old female with complaints of abdominal pain, cramping, nausea and constipation. She has a diagnosis of irritable bowel syndrome (IBS) and had a negative barium enema and a negative abdominal ultrasound. The patient has previously had colonoscopies in 1994 and 1998. The results of those studies were not clear. The patient has now requested authorization for a colonoscopy.  The Health Plan denied her request based upon a determination that the procedure is not medically necessary.It appears from the record the patient has had IBS for some time with symptoms that wax and wane.  Her symptoms are consistent with the diagnosis and diagnostic studies performed thus far have all been negative. It is not clear that any additional information would be gained from a colonoscopy at this time. Therefore, I have determined the requested procedure is not medically necessary for evaluation of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

A 50-year-old male enrollee has requested inpatient hospital services for the treatment of his alcohol dependence and depression. Findings:  The physician reviewer found that from the standpoint of indication for inpatient treatment per se, he was clearly no longer depressed nor suffering any symptoms acutely related to alcohol withdrawal.  The note is also reflective of his being remarkably devoid of any acute symptoms, and it is unlikely that he suddenly garnered huge therapeutic gain in but one more day of treatment. All told, there was no medical indication for inpatient treatment for the date of service in question.
Appeal type: Medical Necessity
Decision: Upheld

A 59-year-old female enrollee has requested bariatric surgery/lap band for the treatment of her obesity. Findings:  The physician reviewer found that This patient is 410 and weighs 164 pounds, resulting in a body mass index (BMI) of 34. She does report comorbid conditions. However, she does not meet the National Institutes of Health guidelines for weight loss surgery. There is potential that further attempts at conservative weight loss will be successful. Furthermore, as the patient has the potential for further weight loss through conservative means, the risks of weight loss surgery outweigh the potential benefits of the procedure.
Appeal type: Medical Necessity
Decision: Overturned

A 36-year-old female enrollee requested authorization and coverage of the medication Allegra. The Health Plan denied the request indicating that the requested medication is not medically necessary for treatment of the enrollees allergic rhinitis.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plans denial on the basis that the requested medication is medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: A 62-year-old male enrollee has requested reimbursement for the gene assay (CPT 84999). Findings:  Three physician reviewers found that The National Comprehensive Cancer Network guidelines indicate that genetic testing such as the DecisionDx-Melanoma gene assay should not be used outside of a clinical trial setting. The use of this type of testing is not considered the standard of care in the treatment of patients with melanoma. The utilization of DecisionDx-Melanoma gene assay is not expected to impact the treatment or health outcome of the patients melanoma. Therefore, the gene assay (CPT 84999) performed was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: 3 of 3 reviewers determined that the testing at issue was 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 dermatology 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 41-year-old female enrollee has requested the services of a reproductive immunologist for treatment of her history of multiple miscarriages.   Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services in this patients case.  The current medical evidence supports low-dose aspirin and heparin therapy or low-dose aspirin and low molecular weight heparin in this clinical setting.  In this patients case, the documentation notes that the patient has been started on anticoagulant treatment and baby aspirin, and this is an appropriate therapy per the current medical literature.  However, this patient does not require the services of a reproductive immunologist.  This is not a rare condition, and literature and recommendations are readily available to obstetrics and gynecology practitioners.  Perinatologists or vascular medicine specialists are often consulted in the management of antiphospholipid syndrome issues.  However, the services of a reproductive immunologist are not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested viscosupplementation injections for treatment of the enrollees knee osteoarthritis.  Findings: The physician reviewer found that based on the available medical records, the requested viscosupplementation injections for treatment of this patients medical condition are not medically necessary. Additional hyaluronan injections is not supported in the evidence based literature. Further, there is a documented possibility of complications such as iatrogenic intraarticular infection and sensitivity reactions which may jeopardize future total knee arthroplasty. This patient has undergone multiple injections and with each injection and each exposure to the antigen, there is an increased risk of allergic response. A recent meta-analysis of the efficacy of viscosupplementation on a total of 89 trials involving 12,667 adults that in patients with knee osteoarthritis viscosupplementation reported a small and clinically irrelevant benefit and that there is an increased risk of serious adverse effects in a patient likely to come to total knee arthroplasty issues of iatrogenic infection (Navarro-Sarabia, et al; Rutjes, et al). All told, the requested viscosupplementation injections (Orthovisc J7324) for both knees are not medically necessary for treatment of this patients knee osteoarthritis.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

The parent of a 1-year, 11-month-old female enrollee has requested for speech therapy for treatment of the enrollees speech delay.  Findings:  The physician reviewer found that the benefit of speech therapy for a developmentally language delayed child has been well documented in the medical literature. Law and colleagues concluded in their meta-analysis of numerous medical studies that children with speech delay can be readily treated. In addition, Goorhuis-Brouwer and Kniff found that cognitively normal and delayed children with delayed speech are candidates for improvement with speech therapy. Further, Buschmann and colleagues addressed the accuracy of speech testing in a 2-year-old population and found that these patients are likely to benefit from speech therapy. All told, speech therapy is medically necessary to address this patients speech and language delays.