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

A 53-year-old female enrollee has requested for Lap Band surgery for treatment of her obesity.  Findings:  The physician reviewer found that documentation of a life-threatening weight related co-morbid condition such as hypertension, sleep apnea or diabetes mellitus, the patient does not meet nationally accepted medical necessity criteria for consideration of weight loss surgery.
Appeal type: Experimental/Investigational
Decision: Upheld

A 55-year-old female enrollee has requested Dynesys Spinal System surgery for the treatment of the enrollees degenerative disk disease and stenosis, L3 to S1.   Findings:  Three physician reviewers found that the patient has multilevel degenerative disc disease and stenosis.  The Dynesys Spinal System is still unproven in the medical literature. While, in theory, it may offer relief of pain with maintenance of motion, there is no long-term, peer-reviewed literature that supports its efficacy or superiority over traditional treatment modalities for overall health benefits.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 36-year-old female with a history of chronic migraine headaches at a frequency of eight to ten per month. She has been treated with a number of medications including Imitrex, Fiorinol and propranolol. She has also received acupuncture treatment, which she states has reduced the number of headaches she experiences a month and has enabled her to reduce her medication use. She is requesting authorization and coverage for continuation of acupuncture at a frequency of once weekly. The Health Plan has denied this request on the basis that weekly acupuncture therapy is not medically necessary.The patient began treatment with an acupuncturist in April 2005 and continued to receive therapy on an irregular basis (e.g., three weeks apart, weekly, five to six weeks apart, etc.) through November 2005. All of the visit notes indicate the patient was slightly better with the exception of the note dated August 2005. On this visit an increase in pain was noted; the patient had hit her head on her cars trunk. Because of the debilitating nature of the patients migraine headaches and her less than favorable response to prescribed medications, she should continue to receive acupuncture treatments; however, the requested frequency of therapy is not medically necessary. Weekly therapy is appropriate in the beginning of treatment when symptoms are most severe or uncontrolled. The patient has been receiving acupuncture therapy since April 2005 and no longer requires weekly visits. She can be appropriately treated at a frequency of twice monthly with, depending upon her response, an eventual reduction in frequency to once monthly. In addition to acupuncture, Headache classes would be medically appropriate and may be helpful.Based upon the information set forth above, I have determined that the requested therapy is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

A 42-year-old male enrollee has requested coverage for Norco for treatment of her chronic low back pain.  Findings:  The physician reviewer found that the patient has not been compliant with following the prescribed medication regimen. There have been inconsistencies, as the prescribed drug has not been present on drug tests. As noted throughout the medical literature, Norco is a potentially addictive medication and stringent controls are therefore in place to monitor its use.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for residential treatment center services for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found that there is sufficient support in the documentation provided for the medical necessity of the services at issue in this clinical setting. During the disputed dates, the patient remained symptomatic. The patient was noted to have angry, anxious, and irritable mood, poor sleep, pressured speech and expressed suicidal ideation. He was aggressive at times and not fully participating in the recommended treatment plan. The patient was documented as having lack of support outside of the treatment facility, high cravings, and high risk of relapse.   At some point in the treatment timeline, the patient stepped down from residential level of care to a sober living facility.  The patient was documented as relapsing and returned to residential treatment. The patient expressed desire to maintain sobriety. The American Society of Addiction Medication (ASAM) criteria have a set of objective guidelines used by clinicians to assist with treatment planning, advocates for service intensity provided in the least intensive but safe treatment setting. ASAM criteria also advise that length of service should be determined by the patients progress with the treatment plan as determined by the patient and treatment providers. In this case, the patient is documented as having high relapse potential, unstable recovery environment, lack of coping skills, lack of understanding of the severity of his use, inability to recognize triggers and poor impulse control as evidenced by his relapse after step-down from residential care. Based on current medical literature, ASAM criteria and the patients documented clinical history, the patients stay at the residential level of care was and is medically necessary for treatment of the patients medical condition.  Final Result: The reviewer determined that the services at issue were and 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the digital breast tomosynthesis for evaluation of the enrollees risk for breast cancer. Findings:  Two physician reviewers found that n the peer-reviewed medical literature, researchers found that the addition of three-dimensional digital breast tomosynthesis to two-dimensional full field digital mammography resulted in a significantly higher cancer detection rate and enabled the detection of more invasive cancers. Thus, although additional studies are needed to confirm these findings, there is adequate data to support the utility of three-dimensional digital breast tomosynthesis in this clinical setting. Final Result: The reviewers determined that the diagnostic procedure 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: Reviewers 1, 2 and 3 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for saturation biopsy (CPT 55706). Saturation biopsy of the prostate involves a transperineal or transrectal ultrasound guided biopsy. A standard biopsy includes sampling of 10-20 cores, while more than 20 cores are obtained using a saturation biopsy. Based on the current medical literature and guidelines, saturation biopsy is not considered standard of care for evaluation of patients with an elevated prostate specific antigen (PSA). The standard of care for this patient would have been magnetic resonance imaging (MRI) and considering a MRI fusion biopsy. Accordingly, the saturation biopsy (CPT 55706) was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Findings:  Two of the three physician reviewers found the saturation biopsy (CPT 55706) 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 services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewers 1, 2, and 3 are board certified in urology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for digital breast tomosynthesis for evaluation of the enrollee, who presented for a breast screening examination. Findings:  Two physician reviewers found that the patient presented for a screening mammogram with digital breast tomosynthesis. The impression was negative, BIRADS 1. The breast tissue was described as average. The patient requested reimbursement for the tomosynthesis portion of the examination. The Health Plan has denied the request for reimbursement for bilateral breast tomosynthesis.  Per the Health Plan, the service at issue was investigational for the evaluation of this patient. There is medical support for the service at issue in this clinical setting. According to one study, 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. Another study noted that integrated two dimensional and three dimensional mammography improves breast cancer detection and has the potential to reduce false positive recalls. Thus, the medical literature supports the use of digital breast tomosynthesis over conventional mammogram due to improved cancer detection rate.  In sum, bilateral breast tomosynthesis performed was likely to have been more effective than other methods of evaluating this patient. Final Result: The 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 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: Experimental/Investigational
Decision: Overturned

A 37-year-old female enrollee requested authorization and coverage of selective laryngeal adductor denervation-reinnervation. The Health Plan denied the request indicating that the requested procedure is experimental for treatment of the enrollees spasmodic dysphonia.Three physician reviewers performed an experimental/investigational Independent Medical Review. All three physician reviewers concluded that the requested procedure is likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy. Because all three physician reviewers concluded that the requested surgery is likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy, the Health Plans denial has been overturned.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for lumbar fusion L5-S1, single level (CPT code 22612). The Health Plan has denied this request indicating that the requested services are not medically necessary for treatment of the patients lumbago. The submitted documentation supports the medical necessity of the requested services. There is moderate evidence supporting the requested services in the settling of lumbar generative disc disease without instability, in the presence of chronic low back pain with failed non-operative treatment, and the presence of S1 radiculopathy on electromyography. Based on the current medical evidence, the requested single level fusion procedure at L5-S1 is medically necessary for the patients medical condition of degenerative disc disease at L5-S1, which did not respond to nonoperative treatment. In sum, the medical evidence supports the requested services in this clinical setting. Therefore, the requested lumbar fusion L5-S1, single level (CPT code 22612) 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 laparoscopic or laparoscopically-assisted vaginal hysterectomy, removal of uterus. Findings:  The physician reviewer found that Tu and As-Sanie note that in the evaluation and management of pelvic pain, gynecologists still lack precise methods to determine when the uterus is the primary problem. The authors further note that hysterectomy in many cases provides a durable solution. Chronic pelvic pain may represent pathology in a specific organ system and/or as a chronic pain syndrome. As chronic pelvic pain may be due to more than one etiology, the goal of evaluation is to identify treatable causes of pain and differentiate specific peripheral causes from those overlapping with centralized pain syndromes. In this case, the patient has a history of pelvic pain. The records document a thorough work-up with history, imaging, and physical examination notable for worsening pain with uterine palpation along with concerns of adhesions and polycystic ovary syndrome (PCOS). The records note that medical management with Depo-Vera failed to control the patients symptoms and led to concerns of low bone density. Given the extent of the patients history, work-up, multi-disciplinary evaluation, and failed medical treatment, the requested service is medically indicated. Therefore, laparoscopic or laparoscopically-assisted vaginal hysterectomy, removal of uterus is medically necessary for the treatment 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 obstetrics and gynecology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for the continuation of physical therapy and continuation of occupational therapy.The submitted documentation does not support that the requested services are medically necessary. The literature on rehabilitation and physical exercise for patients with Guillain-Barre shows a positive association with improved health outcomes with exercise in this population, however the research is limited. The literature on the optimal type of rehabilitation and duration as well as best rehabilitation interventions for Guillain-Barre patients is scant and additional studies with higher methodological quality are needed to validate these findings and evaluate the optimal rehabilitation treatment plan. In this case, the patient's current functional level does not require the continuation of physical therapy and occupational therapy services. The patient has had extensive therapy and his functional level has reached a plateau and does not require continuation of the physical therapy and occupational therapy services that were previously received at the skilled level of care. Accordingly, the requested continuation of physical therapy and continuation of occupational therapy are not medically necessary to treat the patients condition.Final Result: The reviewer determined that the requested services are not medically necessary for the patients condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in physical medicine and rehabilitation, with subspecialty certification in neuromuscular 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

A 55-year-old male enrollee has requested CyberKnife for treatment of his prostate cancer. Findings:  The physician reviewer found that standard therapy for a patient in this clinical situation is hormone therapy followed by external radiation therapy using intensity-modulated radiation therapy (IMRT). Although there is published literature regarding the use of CyberKnife for the treatment of prostate cancer, this is not the standard of care in this setting. In addition, there are no randomized trials in the scientific literature which suggest that CyberKnife produces superior or even equivalent clinical outcomes compared to standard therapy (IMRT). The literature regarding CyberKnife for the treatment of prostate cancer is not mature, and its long-term side effects are not known. As such, the medical necessity of the use of CyberKnife for treatment of this patients condition is not established. Therefore, I have determined that the requested service is not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 52-year-old female has requested Byetta for treatment of diabetes.  Findings:  The physician reviewer found that the patient has become a candidate to continue the Byetta under the Health Plans prior authorization guidelines since she is no longer taking Januvia. Furthermore, records indicate that the patients hemoglobin A1c fell after taking Byetta, indicating good control of her blood sugar. As such, Byetta is clinically appropriate and indicated for treatment of this patients condition.
Appeal type: Medical Necessity
Decision: Overturned

An enrollee has requested authorization and coverage for a Cologuard colon cancer screening test.The submitted documentation supports that the requested services are medically necessary. The Cologuard colon cancer screening test is an FDA-approved test for colon cancer that has been proven to be 92% sensitive for detection of colon cancer, and can detect most (but not all) adenomas if they have high-grade dysplasia. The test is recommended as a first-line test for colorectal cancer screening by the American Cancer Society. In this case, the patient is in the adult population aged between 50 and 75 years, for whom the U. S. Preventive Services Task Force (USPSTF) recommends screening for colorectal cancer. The patient also does not have a family history or personal history that would place him at elevated risk for colorectal cancer. Under these circumstances, the requested Cologuard colon cancer screening test is medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested services are medically necessary for the 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 subspecialty certification in gastroenterology, and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The patient has requested reimbursement for residential treatment center (RTC) services. The American Association of Community Psychiatrists Level of Care Utilization System (LOCUS) provides a reliable framework for determining the appropriate level of care for adults needing mental health treatment. Using LOCUS, providers score patients on a scale of 1-5 using a six-pronged Dimensional Rating System. The six dimensions include: (1) risk of harm; (2) functional status; (3) medical, addictive and psychiatric comorbidity; (4) recovery environment (a. stressors and b. supports); (5) treatment and recovery history; and (6) engagement. The patients composite score is consistent with medically monitored community based services, such as partial hospitalization program (PHP) level of care. Given these findings, the RTC services were not medically necessary for treatment of this patient. Final Result: The reviewer determined that the services at issue were not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in psychiatry with expertise in addiction 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.