Persius/imr-appeals huggingface dataset:
Appeal type: Urgent Care
Decision: Overturned

The parent of the enrollee has requested reimbursement of psychiatric emergency medical services. The Health Plan has denied this request indicating the enrollee did not receive psychiatric emergency medical services. The records indicate that the patient had a recent history of significant depressive and eating disorder symptoms. The patient was also refusing to attend school and behavioral health therapy. These represent acute mental health symptoms. They suggest a possible psychotic episode and affect the patients ability to care for himself. The patient therefore had a psychiatric emergency medical condition, and the care provided was intended to treat that 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 psychiatry with subspecialty 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 a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 58-year-old female who is 64 inches tall, weighing 321 pounds with a body mass index (BMI) of 55.1. She is requesting authorization for gastric bypass surgery. The patient has hepatitis C and other significant comorbid conditions. The patient outlines a significant history of family obesity and attempted weight loss both through supervised and unsupervised diet plans. The patient completed a psychological evaluation and it was recommended that she see a therapist both before and after gastric bypass surgery.  With a BMI of 55.1 and comorbid conditions, the patient meets nationally accepted medical necessity criteria for consideration of weight loss surgery. It is highly likely that gastric bypass surgery will be beneficial for this patient. Furthermore, the patient does not require further dietary workup prior to undergoing weight loss surgery. There is no scientific evidence demonstrating that structured diet or exercise plans have been successful in the treatment of the obese. In fact, the Swedish obesity study identifies that even though there may be reduction or resolution of some symptoms with diet and exercise, surgery has the longest and best long-term outcome for the obese. Moreover, regarding the patients psychological status, the NIH recommends psychological screening for those with eating disorders. This patient has completed a psychological evaluation, which found her in good mental health, well informed about the proposed surgery, and in a stable living situation. The patient should follow through on the recommendation to see a therapist both before and after bypass surgery.Based upon the information set forth above, I have determined the requested surgery is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Overturned

The representative of a 49-year-old male has requested neurological rehabilitation for treatment of a ruptured aneurysm.  Findings:  Three physician reviewers found that neurological rehabilitation therapy is customary treatment for brain injured patients with residual cognitive deficits. Rehabilitation specialists do not consider the therapy experimental or investigational and current research supports its efficacy.  The therapy requested by the patient is reasonable and consistent with the standard of care for treatment of traumatic brain injury.
Appeal type: Medical Necessity
Decision: Overturned

A 36-year-old female enrollee has requested Celebrex for treatment of her traumatic disc herniation and acute radiculopathy.  Findings:  The physician reviewer found that the provider indicates that the patient has failed to achieve pain relief with ibuprofen, Aleve or Lodine. These medications are classified as non-steroidal anti-inflammatory drugs (NSAIDs), which should be sufficient to satisfy the requirement of failure of three NSAIDs prior to authorization for Celebrex. Since this patients records document persistent pain syndrome despite treatment with three NSAIDs, this is adequate justification to conclude that Celebrex is medically indicated for management of her condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for computed tomography (CT) scan of the chest and CT scan of the abdomen. The available records state that this patient presents with a short history of night sweats and weight loss. The patients night sweats have a possible alternative diagnosis in menopause, which should be further considered and ruled out. Per Gaddey and Holder, the patients weight loss does not meet the criteria for the diagnosis of unintentional weight loss in an adult. Per the authors, the definition of unintentional weight loss as greater than 5% loss of a persons weight over the course of six to 12 months. The records do not document the extent nor duration of weight loss to support a diagnosis of unintentional weight loss. In addition, the patients laboratory examinations do not suggest hematologic malignancy. With hematologic malignancy, the lymph cells which become malignant are frequently elevated on a blood test. When the bone marrow is overwhelmed by the growth of these lymph cells or if there is hemolytic stress, patients may have concomitant low red blood cell counts and/or low platelets (Arber, et al.) The patients blood test did not demonstrate elevation in white blood cells, anemia, or thrombocytopenia. The patients urinalysis revealed the possibility of urinary tract infection given the presence of bacteria and elevated WBC esterase. An infection could cause or contribute to the patients night sweats. Moreover, the patient is the appropriate age for menopause, and night sweats can present in the premenopausal, perimenopausal, or postmenopausal stages. Avis and colleagues found that patients who experience night sweats prior to changes in period frequency have the longest duration and most severe night sweats. The patients continued periods do not exclude hot flashes as a cause for her night sweats. Given the presence of plausible alternative diagnoses that require further work-up without imaging, the requested CT studies are not indicated for evaluation of this patient. For these reasons, the requested CT scan of the chest and CT scan of the abdomen are not medically necessary for this patient. Final Result: The reviewer determined that the requested services are not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in neuroradiology with subspecialty certification in diagnostic radiology 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 43-year-old female enrollee requested authorization and coverage of naltrexone for the treatment of pruritic prurigo nodularis.  The health plan denied the enrollees request indicating that the medication 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 medication is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

A 20-year-old female enrollee has requested transcranial magnetic stimulation for treatment of her major depressive disorder.  Findings:  The physician reviewer found that Transcranial magnetic stimulation is a well-tolerated intervention supported by a growing body of evidence in the peer-reviewed literature which demonstrates efficacy for the therapy.  Transcranial magnetic stimulation has been endorsed by the American Psychiatric Association in its current practice guideline for the treatment of individuals with acute phase depression.  However, the guideline notes that there is insufficient evidence supporting transcranial magnetic stimulation for the initial treatment of major depressive disorder.  In this case, since achieving sobriety, the patient had not completed a first-line treatment for depression.  The documentation provided does not describe a structured, evidence-based course of psychotherapy, such as interpersonal therapy or cognitive behavioral therapy, proven effective in the treatment of depression.  Additionally, there is no mention of intermediate treatment settings, such as intensive outpatient services or partial hospitalization programming. Further, the patient was not prescribed standard alternative antidepressants or augmentative medications.  Finally, there is no discussion of or contraindication to electroconvulsive therapy, which remains the proven non-pharmacologic intervention in the treatment of depression to which other stimulatory techniques are measured.  All told, transcranial magnetic stimulation is not medically necessary for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for  proton beam therapy (CPT 77520, 77522, 77523, and 77525). This patient presents with a history of prostate cancer with recent recurrence. A prostate biopsy on 3/15/20 showed involvement of the prostate gland bilaterally by a combination of a Gleason 3+3 and 3+4 adenocarcinoma. The patients provider has recommended proton beam therapy in lieu of standard IMRT and other standard treatment modalities. Proton radiation therapy for prostate cancer in a patient previously treated with radiotherapy to the pelvis has not been demonstrated to be superior to prostatectomy or IMRT. Per the American Society for Radiation Oncology (ASTRO), the comparative efficacy evidence of proton beam therapy with other prostate cancer treatments is still being developed, and thus the role of proton beam therapy for localized prostate cancer within the current availability of treatment options remains unclear. Thus, the requested proton beam therapy (CPT 77520, 77522, 77523, and 77525) 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 proton beam therapy (CPT 77520, 77522, 77523, and 77525) 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 reviewers 1, 2, and 3 are board certified in radiation oncology 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 39-year-old male enrollee has requested for the Dynamic Adjustable Finger Extension Device for treatment of his post comminuted fracture of the proximal interphalangeal joint of the left hand.  Findings:  The physician reviewer found that there is a lack of consistent and quality evidence of the efficacy of splinting of the hand in the effort to gain or retain motion.  It is not clear whether stretching induces lasting motion increases in patients with functionally significant contracture. The use of stretching devices is considered medically necessary in appropriate patients undergoing physical therapy, who are less than four months from the surgery.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Euflexxa injections in the right knee. Evidence from systematic reviews and randomized controlled trials indicate that although viscosupplementation may relieve knee pain in some patients with osteoarthritis, data has not established which patients will benefit. Guidelines from the American Academy of Orthopedic Surgeons (AAOS) indicate that the data on safety and efficacy of viscosupplementation remain inconclusive. As such, the AAOS does not currently recommend viscosupplementation as a routine treatment for osteoarthritis of the knees. Viscosupplementation is reserved for patients with a history of lasting benefit from prior injections and in cases where the remaining options are limited. In this case, the patient has a history of lasting good benefit from prior viscosupplementation. Furthermore, the options are limited. The patient has tried and failed other conservative treatments and arthroscopic surgeries, with the alternative being a total knee arthroplasty. Given this support, the requested Euflexxa injections in the right knee are medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Euflexxa injections. The Health Plan has denied this request indicating that the requested procedures are not medically necessary for treatment of the enrollees right knee osteoarthritis.A review of the record indicates the enrollee was diagnosed with right knee osteoarthritis. Prior conservative treatment included oral medication, bracing, and corticosteroid injections. There was an excellent response to prior administrations of viscosupplementation. There was documentation of subjective, objective, and radiographic imaging results consistent with the diagnosis of advanced osteoarthritis. As such, the request for Euflexxa injections of the right knee is reasonable, appropriate and medically necessary.Final Result: The reviewer determined that the requested services is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

An enrollees parent has requested authorization and coverage for 40 hours per week of direct ABA services. The National Standards Project identifies ample data indicating that ABA is the most effective treatment for children and adults on the autism spectrum. The Behavior Analyst Certification Board (BACB) indicates that the duration of ABA treatment is effectively managed by evaluating the patients response to treatment. The BACB noted that some patients will continue to demonstrate medical necessity and require continued treatment across multiple authorization periods. This definition of treatment does not include an average length of treatment, as there is no one size fits all approach to ABA treatment. Each individual patients treatment is tailored to their specific needs, with some needing treatment for short periods of time, while others will need treatment across the lifespan. In this patients case, although she has made gains in the reduction of problem behaviors, she continues to engage in elevated rates of severe self-injury in the form of head banging. In addition, she has not yet mastered many adaptive and functional goals. Further, her results on testing indicate that she is performing several years below her age level. Given these findings, the requested 40 hours per week of direct ABA services are 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 psychology and is a board certified behavior analyst 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 Butrans 15 mcg/hour patch for the treatment of the enrollees pain. Findings: The physician reviewer found that the submitted documentation supports the medical necessity of the requested medication. The patient has been on the requested medication for the past 18 months. She has recently had increased pain with decreasing activities of daily living. Her total dose is under 120 mg of morphine equivalent. She has followed her opiate maintenance agreement. The patient reported that she experiences pain 24 hours per day. Some degree of tolerance to opiates does develop over time. Given this patients increased pain, the requested medication is medically indicated. Final Result: The reviewer determined that the requested medication 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 anesthesiology with sub-specialty certification in pain 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

The parent of a 16-year-old male enrollee has requested residential treatment for the enrollees generalized anxiety disorder, bipolar disorder, and substance abuse.  Findings:  The physician reviewer found that the medical necessity of residential treatment care provided at the facility from the time frame specified is not supported in the records provided for review. The patient has not had prior outpatient treatment, and does not present any barriers to treatment at that level of care. In addition, there is no documentation of any risk factors such as being a threat to self or others. He was cooperative with treatment and there is no indication in the record that he would not have been able to cooperate and benefit from treatment at a less intensive level. Therefore, the residential treatment care provided at said facility from the time frame specified was not medically necessary for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 66-year-old male enrollee requested authorization and coverage of the medication gleevec for the treatment of metastatic malignant melanoma.  The health plan denied the enrollees request indicating that the requested treatment is experimental.Three physician reviewers performed an experimental/investigational Independent Medical Review.  Each of the three physician reviewers concluded that the medication gleevec is not likely to be more beneficial for the treatment of the enrollees metastatic malignant melanoma 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: Medical Necessity
Decision: Overturned

A 50-year-old female enrollee has requested a pneumatic compression device for treatment of her lymphedema secondary to breast cancer treatment.   Findings:  The physician reviewer found that from review of the available records it appears that this patient has failed an adequate trial of manual therapy as she is not able to maintain reduction of her lymphedema between sessions. However, there is no evidence in the records provided for review that demonstrate use of other conservative methods of care such as elevation and compression bandaging. The provider did make note of some attempts at use of compression garments, thus the patient meets the criteria for a single or multi-chamber non-programmable pneumatic compression device. Since the patient has not been able to successfully maintain edema reduction between PT treatments and the edema interferes with her ability to complete ADLs, a non-programmable multi-chamber pneumatic compression pump is medically necessary. In the medical literature, Wilburn and colleagues conducted a prospective evaluation of the Flexitouch device for maintenance therapy of breast cancer-associated lymphedema. In addition, a review of common treatments for edema secondary to breast cancer concluded that intensive therapies, including pneumatic pumps, yielded greater reduction in volume as compared to self treatments like massage, compression garments or elevation (Moseley, et al). Similarly, the Centers for Medicare and Medicaid Services (CMS) guidelines recommend intermittent compression pumps as the standard of care for treatment refractory lymphedema after trial and failure of four weeks of conservative therapy. All told, the use of a non-programmable pneumatic compression device should be sufficient to manage this patients treatment resistant lymphedema but use of a programmable device has not been established as medically necessary in this clinical setting.
Appeal type: Medical Necessity
Decision: Upheld

A 57-year-old male enrollee has requested orthopedic shoes and insoles for the treatment of his foot pain. Findings:  The physician reviewer found that there is well-established, generally accepted criteria for coverage of orthopedic shoes and insoles for diabetic patients. Medicare requires that a patient must have diabetes and have one of the following complications: peripheral neuropathy with evidence of callous formation, history of pre-ulcerative callous, history of previous ulcer, foot deformity, previous amputation of foot or part of foot, or poor circulation. According to the submitted records, this patient does not demonstrate any of these risk factors or complications. After careful review of the progress notes and the literature, the requested orthopedic shoes and insoles are not medically necessary for treatment of this patients medical condition. A finding of pes planovalgus with arch pain does not constitute medical necessity for diabetic depth shoes and diabetic insoles. Research on therapeutic shoes and insoles for diabetes demonstrates their ability to reduce amputation rates by accommodating biomechanical deformities and reducing shear and frictional forces. However, this patient does not have any of the indications for the requested equipment based on the records provided.