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

A 62-year-old female enrollee requested authorization and coverage of Zelnorm. The Health Plan denied the request indicating that the requested medication is not medically necessary for treatment of the enrollees irritable bowel syndrome.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

A 62-year-old female enrollee has requested for a pneumatic compressor system for treatment of her condition status post massive rotator cuff repair surgery.   Findings:  Three physician reviewers found that there is no peer-reviewed medical literature with long-term clinical trials that proved an electronically controlled thermal unit is more effective and superior to the traditional use of ice packs for cold application to control pain and swelling.  Thus, there is no indication that the device at issue is likely to be more beneficial for treatment of the enrollees medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld

A 54-year-old female enrollee has requested for inpatient skilled nursing facility (SNF) services for treatment of her medical condition status post craniotomy.  Findings:  The physician reviewer found that the patient was safe for transfer and ambulation and safe cognitively by the last authorized date of service. She did need help with bathing and dressing but due to her independence with mobility, continued care and rehabilitation could have been provided at a less intensive level of care than skilled nursing care.
Appeal type: Medical Necessity
Decision: Upheld

A 45-year-old male enrollee requested authorization and coverage of twice-weekly outpatient therapy for the treatment of bi-polar disease and treatment resistant depression. The Health Plan denied the enrollees request indicating that the requested therapy 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 therapy is not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: A 70-year-old male enrollee has requested authorization and coverage for continued transcranial magnetic stimulation (TMS) for up to 26 treatment sessions. The Clinical TMS Society recommends considering continuation or maintenance TMS therapy when other established methods of maintenance antidepressant therapy fail to provide a satisfactory sustained pattern of clinical benefit or a patient has a history of frequent relapse. The initial records did not include clinical documentation to support an indication for maintenance TMS. However, the additional documentation documents the longitudinal illness burden and extent of impairment, psychosocial stressors, and medical comorbidities. Further, the records document improvement in the patients illness burden with prior TMS treatment. Thus, the additional documentation supports the medical necessity of the requested TMS services for up to 26 treatment sessions. Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for  vitamin D screening. Findings:  The physician reviewer found that  The vitamin D receptor is expressed in multiple cells of the body including beta cells and cells involved in immune modulation and most organs in the body including the brain, heart, skin, and prostate. A causal role of vitamin D for bone health has been well established, as vitamin D deficiency is the cause of most cases of rickets and osteomalacia (Bouillon, et al.). In addition, studies have often suggested a link between vitamin D deficiency and conditions such as type 1 and type 2 diabetes, connective tissue disorders, inflammatory bowel disorders, and respiratory infections (Marino, et al.). This patient underwent vitamin D testing due to a history of low vitamin D levels and living in an area that is endemic for low vitamin D levels. As noted in the medical literature, vitamin D deficiency can be related to comorbid conditions and requires appropriate management. Given this patients history of low vitamin D levels and domicile in a region known for vitamin D deficiencies, the vitamin D screening was medically necessary for this patient. Final Result: The reviewer determined that the services at issue were 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 internal medicine with subspecialty certification 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 a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 64-year-old female enrollee has requested for Zometa for treatment of her osteoporosis. Findings:  The physician reviewer found that zometa is FDA approved for the treatment of bone complications from certain forms of cancer, Paget disease, hypercalcemia of malignancy and metastatic bone pain. Zometa is also used to treat osteoporosis in patients who cannot tolerate more standard therapies. This medication is associated with significant improvements in bone mineral density and bone metabolism markers. The safety of Zometa has been established in other applications and the record indicates that the patient has been effectively treated for two years without complications. As typical first-line therapies are not an option in this instance, continued treatment with Zometa is medically indicated.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for lumbar spinal fusion surgery for treatment of the enrollees low back pain. Findings:  The physician reviewer found that the current medical evidence supports the requested services in this clinical setting. Researchers reviewed lumbar spinal fusion performed for chronic low back pain due to degenerative disc disease. A total of 3,060 patients were reviewed. The authors concluded that the body of literature supports fusion surgery as a viable treatment option for reducing pain and improving function in patients with chronic low back pain refractory to nonsurgical care when a diagnosis of disc degeneration can be made. The authors noted that substantial improvement can be expected in patients with chronic low back pain and degenerative disc disease with a fusion. In this case, there is evidence of degenerative disc disease at L4-L5 with moderately severe loss of height. There is sufficient support for the requested services in this clinical setting. All told, lumbar spinal fusion surgery 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: Experimental/Investigational
Decision: Overturned

A female enrollee requested lysis of epidural adhesion procedures for treatment of her medical condition.  Findings:  Two physician reviewers found that the lysis of epidural adhesion procedures billed with CPT code 62311 were likely to be more beneficial for treatment of the patients medical condition than other modalities. However, the lysis of epidural adhesion procedure billed with CPT code 62319 (epidural catheter placement) was not clinically indicated. In this clinical setting CPT 62311 was appropriate and likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Urgent Care
Decision: Upheld

A 36-year-old male enrollee has requested emergency services for treatment of his perineal discomfort.  Findings:  The physician reviewer found that the submitted documentation indicates the patient had perineal swelling of significant size. However, the medical records do not mention the severity of pain and there is no documented evidence of systemic symptoms associated with the infection. While perineal swelling of this size would be cause for some concern by a layperson, there is no documented evidence of the abscess rapidly enlarging, any systemic symptoms, or severe pain. The problem had been going on for several days and the patients arrival time at the Emergency Department was only four to five hours prior to the time a primary care providers office would have opened and could have been contacted. As such, a prudent layperson would not have thought this to be an emergency medical condition and would not have sought immediate medical attention on the date indicated.
Appeal type: Experimental/Investigational
Decision: Upheld

An enrollee has requested reimbursement for the digital breast tomosynthesis performed. Findings:  The physician reviewer found that tomosynthesis is a technique that was developed several years ago as a problem solving adjunct to routine mammography. Applying the same basic concept as computed tomography (CT) scanning, by separating the various layers of breast tissue, one can better detect abnormalities. However, in this particular patient, there were no problems to be resolved since the patient did not have dense breasts, she did not have a mass, there were no palpable lumps, and she did not have suspicious calcifications. The two-dimensional (2D) images were reconstructed from the primary tomosynthesis acquisition, thus a routine mammogram would have been sufficient. Tomosynthesis has not been shown to provide significant increased value in patients who do not have dense tissue that could obscure an abnormality. For these reasons, the use of the digital breast tomosynthesis performed 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 diagnostic procedure 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: the physician reviewers are board certified in diagnostic radiology 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: A male enrollee has requested authorization and coverage for Mavyret 100-40 mg tablets for four weeks. According to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with limited life expectancy due to nonliver-related conditions. The guidelines recommend that all patients should be treated, regardless of fibrosis stage. The guidelines recommend that non-cirrhotic treatment-naive genotype 3 patients should be treated with Mavyret for eight weeks. These recommendations apply regardless of fibrosis stage. A trial showed a 95% cure rate with eight weeks of treatment. Although 12 weeks of Mavyret is recommended in patients with compensated cirrhosis, the patient does not have any evidence of compensated cirrhosis; stage 3 liver fibrosis is distinct from cirrhosis (stage 4 fibrosis). Additionally, the patient has already completed eight weeks of therapy based on the provided information; a restart of four additional weeks after a gap without therapy is not in accordance with guidelines or FDA approval for the use of Mayvret.  For these reasons, the requested treatment with Mayvret for an additional 4 weeks is not supported as medically necessary for the treatment of this patients hepatitis C infection.Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Crinone 8% gel. The Health Plan has denied this request indicating that the requested medication is not considered investigational for treatment of the enrollee who is in her first trimester of pregnancy. Findings:  The medical literature does not support the superior efficacy of the requested medication in this clinical setting. Supplemental vaginal progesterone therapy is not routinely prescribed for women with recurrent pregnancy loss (RPL) once a pregnancy has been established. Treatment with vaginal progesterone therapy has not been shown to increase live birth rate. Although there are other smaller studies with variable results, these studies are include small sample size, poor methodology, and variable preparations of progesterone. Current guidelines from the American Society for Reproductive Medicine are based on the large randomized trial that do not support supplemental vaginal progesterone therapy for the treatment of recurrent pregnancy loss once a pregnancy has been established. For these reasons, Crinone 8% gel is not likely to be superior to other methods of treating this patients medical condition.Final Result: All three reviewers have determined the requested medication is 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:  All three reviewers are board certified in obstetrics and gynecology and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for modified duodenal switch weight loss surgery. The requested duodenal switch is a standard procedure for the treatment for morbid obesity. Duodenal switch has the greatest weight loss and improvement of metabolic outcomes, with durability of greater than ten years, and the least weight regain of any bariatric operation, far less than gastric bypass. In this case, the patient meets all accepted criteria for bariatric surgery including a body mass index (BMI) that is at least 40 kg/m2 and failure of conservative weight loss efforts. A pre-bariatric surgery psychological assessment did not reveal psychological contraindications, and completion of a multidisciplinary evaluation did not reveal dietary contraindications. Therefore, modified duodenal switch weight loss surgery (CPT 43845) is likely to be more beneficial for treatment of the patients condition than any available standard therapy.Findings:  Twho of the three physician reviewers found the requested modified duodenal switch weight loss surgery is 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 service is 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: Physician reviewers 1, 2, and 3 are board certified in general surgery 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: Experimental/Investigational
Decision: Upheld

A fifty-three year-old male who has been diagnosed with advanced osteoarthritis is requesting authorization for hip resurfacing arthroplasty.   Reviewers Findings:  Two of the three reviewing physicians found that the limited evidence of long-term safety and efficacy it cannot be said the proposed hip resurfacing is likely to produce a better clinical result than conventional total hip replacement.  The third physician found that the procedure represents a viable option for patients with disabling arthritis, particularly those under 55.  The reviewing physicians found that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a 17-year-old female enrollee has requested  residential treatment services for treatment of the enrollees behavioral health condition.  Findings:  The physician reviewer found that the submitted documentation does not establish the medical necessity for residential treatment from the said date onward. The patients status has not changed significantly during her time at this facility, and medication management has not been aggressive. The materials submitted document less than five hours per week of active treatment, and there has been minimal containment of suicidal impulses. The patients condition has not changed appreciably at this level of care. American Psychiatric Association practice guidelines indicate that individuals with PTSD should be treated in the least intensive setting which is likely to be safe and effective. For patients such as this patient with cluster B traits, Dialectical Behavioral Therapy (DBT) is appropriate and indicated therapy. Thus, according to current evidence-based practice standards, this patients needs could best be met in an intensive outpatient program with a focus on DBT. All told, residential treatment during this period of time was not and is not medically necessary for this patient. The patient could have been treated at a less intensive level of care.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested reimbursement for platelet rich plasma injection for treatment of the enrollees foot and ankle pain.  Findings:  The physician reviewer found that after careful review of the enclosed information and the pertinent guidelines concerning platelet rich plasma injections for plantar fasciitis, platelet rich plasma injection is not considered more beneficial than standard treatment for this patients right heel pain. Currently, most of the studies on platelet rich plasma injections have been performed for the treatment of lateral epicondylitis. The medical literature states that platelet rich plasma injections may improve plantar fasciitis treatment outcomes, but the treatment is still not considered standard of care. Moreover, most of the studies recommend further double blind placebo controlled studies to evaluate the efficacy of platelet rich plasma injections for treatment of plantar fasciitis. For these reasons, the platelet rich plasma injection was not likely to have been more effective than the standard methods available in treating this patients medical condition.Final Result: All three reviewers determined the services at issue were 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:  All three reviewers are board certified in podiatry and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The parents of a three-year-old male enrollee have requested neurofeedback (cognitive rehabilitation therapy) for the treatment of the enrollees autism. Findings:  The physician reviewer found that neurofeedback is not medically necessary in this setting.  Research on patients with autism and the use of neurofeedback is mixed and is not adequate to support the use of the therapy in this patient population. There are no randomized, controlled studies or trials to support the use of neurofeedback in autism. As mentioned previously, although gains were noted in this case, the patient was receiving several proven therapies, and thus his improved functioning was likely due to these established treatments.
Appeal type: Medical Necessity
Decision: Upheld

A 34-year-old female requested authorization and coverage of autologous cultured chondrocyte implantation (Carticel). The Health Plan denied the request indicating that the requested procedure is not medically necessary for treatment of the enrollees chondral defect.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.