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

A 50-year-old male enrollee requested Stelara 90 mg every eight weeks for medical treatment of his psoriasis.  Findings:  The physician reviewer found that Stelara is a human monoclonal antibody indicated for use in adult patients with moderate to severe plaque psoriasis who are candidates for phototherapy or systemic therapy. Stelara every 12 weeks is effective for most patients with moderate-to-severe psoriasis, intensification of dosing to once every eight weeks with Stelara 90 mg might be necessary to elicit a full response in patients who only partially respond to the initial regimen. Consistent with these findings, the requested Stelara 90 mg dosing every eight weeks is supported as medically necessary for treatment of this patients psoriasis.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for surgical procedures including. The records provided for review document that the inferior alveolar nerve and its terminal branch, the mental nerve, are damaged. However, some nerve conduction is still present resulting in dysesthesias about one year after the trauma. This finding supports a differential diagnosis of axonotmesis or neuroma, both of which are treated by nerve graft, and supports the need for nerve suture and nerve graft. The patients lip ptosis is secondary to scarring from both the surgery and the subsequent infection, which were a result of the initial trauma. Thus, lip repair is also supported as medically necessary. The success rate for inferior alveolar nerve repair is 87%, resulting in an improvement in sensation and subsequently function (Motamedi). For these reasons, the requested surgical procedures including lip repair; nerve suture; and nerve graft are medically necessary. The California reconstructive surgery statute requires health insurers to cover reconstructive surgeries, defined as surgery performed to correct or repair abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease to do either of the following: (1) to improve function; or (2) to create a normal appearance, to the extent possible. Applying this statute, the requested surgical interventions are reconstructive in nature. The patients condition constitutes an abnormal structure of the body, and it was caused by trauma which is the initial reason for her hospital admission and subsequent surgery. The recommended surgical procedures will address the patients functional issues related to her condition and create a more than minimal improvement in the patients appearance. All told the requested surgical procedures are reconstructive in nature for the treatment of this patient. Given this support, the requested surgical procedures are medically necessary and reconstructive in nature for the treatment of this patient.Final Result: The reviewer determined that the requested services are medically necessary and reconstructive in nature for the treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in oral-facial and maxillary 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: Upheld

A 32-year-old male enrollee requested authorization and coverage of intradiscal electrothermal therapy (IDET) for treatment of chronic back pain.  The health plan denied the enrollees request indicating that IDET is considered experimental.Three physician reviewers performed an experimental/investigational Independent Medical Review.  Each of the three-physician reviewers concluded that IDET is not likely to be more beneficial for treatment of the enrollees back pain than any available standard therapy.  Because all three physician reviewers concluded that the requested treatment is not likely to be more beneficial for treatment of the enrollees medical condition than any available standard therapy, the review organization upheld the health plans denial.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Zoll LifeVest wearable cardioverter defibrillator. Findings:  The physician reviewer found that The documented high-risk of sudden cardiac death in patients with severe left ventricular dysfunction has led to the recommendation of implantable cardioverter defibrillators. Current data from multiple trials support the use of a wearable cardioverter defibrillator, such as the Zoll LifeVest, following an initial diagnosis of severe left ventricular dysfunction with an ejection fraction of 35% or less (Kutyifa, et al.; Klein, et al.; Epstein, et al.). The placement of a LifeVest is planned for 90 days after initial diagnosis of severe left ventricular dysfunction. This timeframe allows for possible improvement in the patients ejection fraction while on guideline-directed medical therapy, which could avoid the need for an implantable cardioverter defibrillator. According to the records, this patients ejection fraction was 20-25%. The provider noted that the patients ejection fraction improved over time and the LifeVest was appropriately removed within the 90-day window, as per accepted guidelines and in accordance with the standard of care. For these reasons, the Zoll LifeVest wearable cardioverter defibrillator was 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 Zoll LifeVest wearable cardioverter defibrillator was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The 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: Physician reviewers 1, 2, and 3 are board certified in internal medicine with subspecialty certification in cardiovascular disease 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: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested reimbursement for Afirma gene testing CPT 81210-59 (BRAF gene analysis); CPT 81275-59 (KRAS gene analysis); CPT 81311-59 (NRAS gene analysis); CPT 81401-59 (Level 2 molecular pathology procedure); and CPT 81406-59 (Level 7 molecular pathology procedure). Findings:  The physician reviewer found that While a fine needle aspiration (FNA) biopsy of a suspicious thyroid nodule is typically an accurate means of assessing whether the nodule is benign or malignant, Rao and Bernet indicated that up to approximately 30% of FNA biopsy results are considered to be indeterminate, and the risk of malignancy in these cases are highly variable. When patients with cytologically indeterminate thyroid nodules undergo diagnostic surgery, Kloos states that approximately three-quarters prove to be benign on surgical histopathology. Liu and colleagues concluded, The Afirma gene expression classifier measures 167-gene messenger ribonucleic acid (mRNA) expression panel of thyroid nodules to distinguish benign and malignant nodules. The Afirma gene testing has significantly prevented avoidable thyroid surgeries. Therefore, Afirma gene testing CPT 81210-59 (BRAF gene analysis); CPT 81275-59 (KRAS gene analysis); CPT 81311-59 (NRAS gene analysis); CPT 81401-59 (Level 2 molecular pathology procedure); and CPT 81406-59 (Level 7 molecular pathology procedure) provided was likely to have been moFindings: Three out of three physician reviewers found that Afirma gene testing CPT 81210-59 (BRAF gene analysis); CPT 81275-59 (KRAS gene analysis); CPT 81311-59 (NRAS gene analysis); CPT 81401-59 (Level 2 molecular pathology procedure); and CPT 81406-59 (Level 7 molecular pathology procedure) provided was likely to have been more beneficial for the enrollee than any available standard therapy.re beneficial than standard therapy to evaluate the patients medical condition. Final Result: The reviewers determined that the service at issue was likely to have been more beneficial than any available standard treatment for the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer 1, reviewer 2, and reviewer 3 are board certified in board certified in internal medicine with sub-specialty certification in endocrinology, diabetes, and metabolism. All reviewers 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the breast tomosynthesis screening mammogram for the evaluation of the enrollees risk of breast cancer. Findings:  Two physician reviewers found that in the presence of breast implants it is important to obtain implant displacement views, which was done in this case. In addition, the patient has breasts that have been described as heterogeneously dense. It is specifically patients who have dense breasts that can benefit most from tomosynthesis. The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor. Final Result: Two reviewers determined that the service at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: All three 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: The patients parent has requested authorization and coverage for 10 hours per week of applied behavior analysis (ABA). Based on the presenting information, the requested 10 hours per week of ABA services are not medically necessary for treatment of this patient due to the absence of a current evaluation and treatment plan. The patient received negative autism diagnosis across several years from providers that included structured autism assessments such as the Autism Diagnostic Observation Schedule, Second Edition (ADOS-2). The positive assessments were performed without use of standardized measures. While a standardized measure alone is insufficient to make a diagnostic determination, they are an important aspect to accurately assess a patients symptoms, rather than relying solely on caregiver reports. In this case, the patient did not meet the criteria for autism utilizing standardized autism measures. The providers who diagnosed the patient with autism did not include standardized testing. In addition, the supporting documentation does not include a treatment plan outlining treatment goals to determine whether the requested 10 hours of ABA services would be sufficient, or excessive. The Behavior Analyst Certification Board (BACB) highlights that a treatment plan is important to identify the scope and intensity of treatment. There is no treatment plan assessing and outlining the patients skill deficits, rate of problem behavior, and goals to address the patients current diagnoses. Without a treatment plan covering these areas, the requested 10 hours per week of ABA services are not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is a BCBA and board certified in psychology, 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 patient has requested authorization and coverage for Gammagard intravenous immunoglobulin (IVIG) (10%/120 grams, every four weeks). Liu and colleagues note that small fiber polyneuropathy has various underlying causes, including associations with systemic autoimmune conditions, while Morrison and Chaudhry note that a large number of medications and toxins may also produce neuropathy. Geerts and colleagues note that in the first double-blind, randomized, controlled trial evaluating the efficacy and safety of intravenous IVIG versus placebo in patients with idiopathic small fiber neuropathy, IVIG treatment had no significant effect on pain in patients with painful idiopathic small fiber neuropathy. In this clinical setting, given the limited evidence in current medical literature supporting the use of IVIG in the treatment of small fiber neuropathies, the requested service is not medically indicated. Therefore, Gammagard IVIG (10%/120 grams, every four weeks) is not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested service 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 neurology with sub-specialty certification in vascular 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for transcranial magnetic stimulation (TMS) treatment for treatment of the enrollees behavioral health conditions. Findings:  The physician reviewer found that the submitted documentation supports the requested services in this clinical setting.  Based on the patients PHQ-9 score, it appears that he has moderately severe depression.  The current literature on TMS does not indicate that this treatment needs to follow numerous medication failures. This patient does not appear to have any comorbid substance abuse or personality disorders. Most of the literature supporting TMS considers comorbid disorders to be exclusionary. The evidence-based literature for TMS has grown over the past several years. There is supporting evidence in the literature that numerous medication trials do not often yield higher levels of success. All told, the requested TMS treatment 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 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: An enrollee has requested authorization and coverage for Euflexxa injections for treatment of the enrollees osteoarthritis of the knees. Findings:  The physician reviewer found that evidence based medical peer reviewed literature supports the use of repeat viscosupplementation injections for the treatment of pain in patients with osteoarthritis of the knee. Colleagues concluded that hyaluronic acid was the best pharmacologic intervention for knee osteoarthritis in their meta-analysis of 137 studies with 33,243 participants. Hyaluronic acid was found to be better than injected placebo or injected corticosteroids. Colleagues conducted a systematic review of overlapping meta-analyses comparing intra-articular hyaluronic acid with other non-operative treatment modalities for knee osteoarthritis. They reported that the current highest level of evidence suggests that intra-articular hyaluronic acid is a viable option for knee osteoarthritis.  The American Medical Society for Sports Medicine (AMSSM) recommends hyaluronan acid for appropriate knee osteoarthritis patients, based on a very large network meta-analysis. Viscosupplementation has been found to be safe and effective and allow for delay of total knee replacement, and more effective than corticosteroid injections. This patient presents with left knee pain with associated effusion. She reported functional difficulty in walking and getting up from seated positions. Clinical examination findings are consistent with reported radiographic evidence of moderate left knee osteoarthritis. She had failed to improve with at least three months of NSAIDs and a recent corticosteroid injection. Therefore, the request for Euflexxa injections is medically necessary for treatment of this 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 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 34-year-old female enrollee has requested a bariatric surgery consultation prior to the completion of the 24-week Options Program for treatment of her morbid obesity.  Findings:  The physician reviewer found that with a BMI of 41.27 the patient meets nationally accepted medical necessity criteria for consideration of weight loss surgery. It is highly likely that bariatric surgery will be beneficial for her. Furthermore, the patient does not require the completion of the Options Program prior to surgical consultation. There is no scientific evidence demonstrating that there is any benefit in delaying weight loss surgery in order for a patient to complete a health plan mandated program.
Appeal type: Medical Necessity
Decision: Overturned

Findings:  The physician reviewer found that The patient has requested authorization and coverage for magnetic resonance imaging (MRI) of the lumbar spine. The American College of Radiology (ACR) appropriateness criteria for the evaluation of inflammatory back pain with known or suspected axial spondyloarthritis notes that MRI of the sacroiliac joints and areas of interest in the spine may be appropriate following radiographs. MRI findings may demonstrate inflammatory changes such as spondylitis, spondylodiscitis, inflammation of the facet joints, or enthesitis, and may aid in diagnosis and affect treatment planning. In this case, given this patients ulcerative colitis and spondylarthritis, and as prior MRIs demonstrated significant disease at L4-L5, the requested service is medically indicated for further evaluation of this patient. Therefore, MRI of the lumbar spine is medically necessary for the evaluation of this patient.Final Result: The reviewer determined that the requested service is medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested breast tomosynthesis for evaluation of her breast cancer screening. Findings:  Two physician reviewers found that peer reviewed literature supports the use of tomosynthesis in this clinical setting. Per Skaane and colleagues, the use of mammography plus tomosynthesis in a screening environment resulted in a significantly higher cancer detection rate and enabled the detection of more invasive cancers. Ciatto and colleagues state that integrated two dimensional and three dimensional mammography improves breast cancer detection and has the potential to reduce false positive recalls. For these reasons, tomosynthesis was likely to be more beneficial than any available standard therapy. Final Result: Two reviewers determined that the services at issue were likely to be more beneficial for evaluation 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 diagnostic radiology 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

A 70-year-old female enrollee has requested for readmission to acute inpatient rehabilitation at or continued skilled nursing level of care, occupational, physical, and/or speech therapy for treatment of the enrollees medical condition status post acute ischemic stroke.  Findings:  The physician reviewer found that there is strong evidence that early stroke intervention improves outcomes beyond early intervention, particularly acute hospital-based services in the immediate few days following a stroke, the outcomes do not differ between acute, subacute or home-based services. Since the rate of recovery is dependent upon neurological recovery, more time is needed for severe injuries. However, as there is no benefit to be gained with a transfer to an acute rehabilitation hospital at this stage in her recovery process, the requested services have not been shown to be medically necessary in the management of this patients medical condition.