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

The patient has requested authorization and coverage for acupuncture services at least sixteen (16) times per year. The patient has been diagnosed with hyperlipidemia, polyosteoarthritis, essential hypertension, and unilateral inguinal hernia. The patient reported upper and lower extremity joint pain. Physical examination findings included tenderness to palpation of the knee joints, hand joints, and wrist joints. In this case, there was no documentation of pre- and post-acupuncture baselines for comparison purposes. After an unknown number of prior acupuncture sessions, there was no documentation of the total number of sessions completed and any specific, measurable, objective functional improvement to support the reasonableness and necessity of any additional acupuncture sessions. The medical evidence does not support the requested services in this clinical setting. Therefore, acupuncture services at least sixteen (16) times per year 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 licensed O.M.D., L.Ac. 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 62-year-old male enrollee has requested extensive decompression and fusion of the lumbar spine (L4-5 and L5-S1) for treatment of his degenerative disc disease and canal stenosis.  Findings:  The physician reviewer found that lumbar fusion is indicated for well selected patients with degenerative, traumatic, congenital, or post-operative spinal deformity, or single level documented discogenic back pain in the absence of radicular symptoms. The presence of back pain in addition to lumbar radiculopathy, in the setting of lumbar degenerative disease and spinal stenosis, does not support fusion during an initial operative intervention. The medical literature stresses the importance of careful patient selection for increasing success in complex clinical situations. The records submitted and reviewed do not provided adequate rationale or justification to support an extensive instrumentation and fusion surgery over a simple decompression as a first-line operative approach. Consistent with these findings, the requested decompression L4-5 and L5-S1 is medically necessary, while the requested fusion is not medically necessary for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 38-year-old female has requested radiofrequency lesioning for treatment of shoulder pain.  Findings:  Two physician reviewers found that the patient developed the pain after a fall. She has been treated with epidural injections along with suprascapular nerve blocks, physical therapy, and opioid therapy. She was determined not to be a candidate for suprascapular nerve decompression. Her diagnosis includes a multitude of problems including cervical radiculitis and thoracic outlet syndrome. The patient has requested authorization and coverage for radiofrequency lesioning, which has been denied by the Health Plan as investigational. The proponents of suprascapular nerve block consider it to be an important procedure and have described its technique (Fernandes, et al). However, there is a paucity of support for neurolytic procedures in the medical literature (Liliang, et al). Pulsed radiofrequency lesioning of the suprascapular nerve has been reported in case reports and only preliminary reports (Keskinbora and Aydinli). However, there have not been any properly performed studies showing the effectiveness, and indications for radiofrequency thermoneurolysis.
Appeal type: Medical Necessity
Decision: Overturned

A 35-year-old female enrollee has requested for gastric bypass surgery for treatment of her morbid obesity. Findings:  The physician reviewer found that with a BMI of 42.3 and early comorbidities, the patient meets the National Institute of Healths medical necessity criteria for consideration of weight loss surgery. It is highly likely that gastric bypass will ameliorate or eliminate her co-morbid conditions. Recent studies indicate that bariatric surgery is associated with decreased over all mortality for the morbidly obese. However, although medically the patient meets criteria for consideration of weight loss surgery, she has not yet obtained psychological clearance for the procedure.
Appeal type: Medical Necessity
Decision: Upheld

A 69-year-old female enrollee requested authorization and coverage of a DEXA scan. The Health Plan denied the request indicating that the requested DEXA scan is not medically necessary for evaluation of the enrollees bone density.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested DEXA scan is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

A 49-year-old female enrollee requested authorization and coverage of bilateral blepharoplasty. The Health Plan denied the request indicating that the requested procedure is considered cosmetic and is not medically necessary for the treatment of the enrollees eyelids.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 cosmetic in nature and not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

A 32-year-old female enrollee has requested disc nucleoplasty surgery for the treatment of her chronic low back and leg pain. Findings:  The physician reviewer found that among the therapeutic options to emerge for the treatment of back pain and radiculopathy are a plethora of minimally invasive treatments aimed at removing nuclear material and lowering intradiscal pressure through devices inserted percutaneously into intervertebral discs.  Various techniques are utilized in managing discogenic pain, with or without disc herniation.  Percutaneous techniques are touted to replace traditional open surgery in operations requiring discectomy, decompression, and fusion. Percutaneous access to the disc was developed in the 1970's.  Technical advances in the use of intradiscal therapies led to the development of intradiscal electrothermal therapy (IDET), DISC Nucleoplasty, and DeKompressor, along with laser-assisted, endoscopic, and Nucleotome disc decompressions.  The indications for percutaneous lumbar disc decompression include low back and lower extremity pain caused by a symptomatic disc. Despite advances in such treatments there remains insufficient scientific data demonstrating that nucleoplasty decompression is an effective long-term alternative to other standard therapies such as open surgery. In fact, there is no evidence to support nucleoplasty decompression as more clinically efficacious than surgery. Based upon the lack of data to support the efficacy of nucleoplasty decompression, it cannot be considered medically necessary for this patient.
Appeal type: Medical Necessity
Decision: Upheld

A 22-year-old female enrollee has requested a power scooter for treatment of her avascular necrosis of the hips secondary to Crohns disease.  Findings:  The physician reviewer found that power mobility devices are considered medically necessary when they are needed in order to safely perform activities of daily living in the home. Patients who qualify for coverage are unable to ambulate within the home despite the use of an assistive device and are unable to self-propel a manual wheelchair. In the case under review, the records suggest that the patient is ambulatory but is requesting a power scooter for use outdoors while traveling between classes. The use of a power scooter for this purpose does not meet the generally accepted guidelines for medical necessity as published by the Centers for Medicare and Medicaid (CMS). Thus, the requested equipment has not been established as medically necessary for treatment of this patients condition and the denial was appropriate.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for bariatric surgery with Orbera intragastric balloon (CPT 43999). The records provided for review document that this patient has Class III obesity with a body mass index (BMI) of 47.2 kg/m2. The provider has recommended the Orbera intragastric balloon, which is U.S. Food and Drug Administration (FDA) approved for the treatment of obesity in patients with a BMI of 30-40 kg/m2 (Courcoulas, et al.; Vyas, et al.). The Orbera intragastric balloon lacks data supporting its use in patients with a BMI over 40 kg/m2. In addition, the guidelines from the American College of Cardiology (ACC), American Heart Association (AHA), and the Obesity Society do not recommend intragastric balloon therapy for long-term obesity therapy (Jensen, et al.). Alternatives, such as bariatric surgery, are recommended in patients with a BMI of 40 kg/m2 or higher, and multiple options such as pharmacotherapy are also supported (Jensen, et al; Kim, et al). For these reasons, the requested bariatric surgery with Orbera intragastric balloon (CPT 43999) is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings:  Three of the three physician reviewers found the requested bariatric surgery with Orbera intragastric balloon (CPT 43999) is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewer 1 is board certified in internal medicine with subspecialty certification in gastroenterology and is actively practicing. Physician reviewer 2 is board certified in surgery and is actively practicing. Physician reviewer 3 is board certified in surgery with subspecialty certification in bariatric and minimally invasive surgery and is actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 26-year-old female enrollee has requested reimbursement for psychiatric residential treatment center services provided over a two-week period for treatment of the enrollees behavioral health issues.  Findings:  The physician reviewer found that based on review of the available records, this 26-year-old patient was admitted to residential treatment for management of anorexia nervosa. She was generally non-compliant with feeding and routine on the unit, and persistently displayed poor judgment in deliberately harming herself with food restriction. Her admission to the residential program terminated after an intentional overdose. Consistent with the American Psychiatric Association (APA) treatment guidelines, this overdose provides evidence that the patient could not have been managed safely in a lower level of care. Her admission to a center for residential treatment was appropriate to treat the patients condition. The records indicate that management of this patients condition could not have been provided safely on an outpatient basis or less restrictive setting and was consistent with standards of good medical practice. As such, the services provided were medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient requested residential treatment program services that were provided were medically necessary for the treatment of the patients medical condition. Findings:  The physician reviewer found that the Child and Adolescent Level of Care Utilization System (CALOCUS), developed as a collaboration between the American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists, is a level of care assessment tool used by behavioral health managers and clinicians to support accurate level of care recommendations. The six dimensions of CALOCUS include risk of harm, functional status, comorbidity, recovery environment, resiliency and treatment history, and acceptance and engagement. During treatment, the patient was noted to be cooperative and showed insight into her need for continued treatment. The patients composite CALOCUS score is 15, which indicates an outpatient services level of care. Given these findings, the patient did not require the intensity, supervision and medical management provided at the residential treatment center level of care. Therefore, residential treatment program services that were provided were not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested services 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 subspecialty certification 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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for tertiary care services. The records provided for review document that this patients medical history and current treatment plan are complex. Her provider has recommended a treatment regimen consistent with current National Comprehensive Cancer Network (NCCN) guideline recommendations. Given the presence of brain metastases, the requested services of a large cancer center with extensive experience in interdisciplinary care is indicated. Specialized cancer centers are designated as such by the National Cancer Institute (NCI) in a highly competitive peer-reviewed process. The documentation reviewed supports treatment at an NCI-designated cancer tertiary care center. Therefore, the requested tertiary care services are medically necessary for treatment of this patient. Final Result: The reviewer determined that the services at issue were 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 medical oncology with subspecialty certification in hematology 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 enrollee has requested authorization and coverage for cervical epidural steroid injection (CESI). The Health Plan has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees chronic neck pain.Overall, there is good evidence for the effectiveness of cervical interlaminar epidural injections in managing cervical disc herniation and fair evidence in managing central spinal stenosis and post surgery syndrome. The operative report pertains to the interlaminar epidural injections. These injections are noted to be safe and effective. Two injections have been given to this patient with good long term results with the first injection given, and reports of one week relief with the second injection. Based on the review of the literature, the injections are safe and effective. The patient reports severe pain and is in need of pain relief in a rapid, safe, and effective manner. As such, the documentation provided supports the medical necessity of the requested CESI for the management and 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 orthopedic surgery. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a nine-year-old female enrollee has requested for a custom pediatric wheelchair with power option  for treatment of the enrollees metabolic disorder and mitochondrial disease.  Findings:  The physician reviewer found that Beauchamp and colleagues reviewed 170 muscular assessments on 33 patients with Friedreichs Ataxia with an average follow-up of 6 years. The authors reported that it was possible to delineate a fairly regular and statistically significant pattern of slowly progressive and symmetrical loss of strength affecting mainly the lower limbs, and more specifically the pelvic girdle muscles. The first significant weakness was observed in the hip extensor group, followed in a variable fashion by other muscle groups of the lower limb. Upper limb and trunk muscles remained relatively spared until late in the disease process, with total strength approximately 80% of normal. Use of a wheelchair began at a mean age of 18.2 years, at which time the lower-limb strength averaged 70% of normal. The fact that the patient has been utilizing a wheelchair due to her fatigue and muscular deficits supports the necessity of the requested device.
Appeal type: Experimental/Investigational
Decision: Overturned

A 60-year-old male enrollee has requested esophagus endoscopic ablation (radiofrequency ablation) for treatment of his Barretts esophagus. Findings:  Three physician reviewers found that Barretts esophagus predisposes an individual to cancer development. The annual incidence of esophageal cancer for the general population of patients with Barretts esophagus is approximately 0.5% per year.  Some reports suggest a higher risk for patients with long segment Barretts esophagus and a greater risk in men as compared with women. As noted by the American Gastroenterological Association, radiofrequency ablation for patients with low-grade dysplasia leads to reversion to normal appearing squamous epithelium in greater than 90% of cases.  Overall, in this patients case, the requested radiofrequency ablation is likely to be superior over other methods of treatment.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for transcranial magnetic stimulation (TMS). Current medical literature supports the use of TMS for severe, recurrent major depressive disorder that is unresponsive to medication management and psychotherapy treatment. Researchers note that multiple randomized controlled trials and published literature have supported the safety and efficacy of TMS antidepressant therapy in the treatment of major depressive disorder. In this case, the patient has a diagnosis of major depressive disorder and has consistently been in cognitive behavioral therapy, along with trials of antidepressants, a mood stabilizer, and atypical antipsychotics without improvement in his symptoms and continued difficulty in functioning. The records document that following TMS therapy, the patient reported almost complete remission of his depressive symptoms, demonstrating the efficacy of TMS in this clinical setting. In this patients case, TMS was in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, TMS was clinically appropriate in terms of type, frequency, extent, site, and duration. TMS was not primarily for the economic benefit of the health care service plan and subscribers or for the convenience of the patient, treating physician, or other health care provider. Therefore, TMS was medically necessary for the treatment of this patient.Final Result: The reviewer determined that the services at issue were 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 parent of an enrollee has requested authorization and coverage for a nutrition evaluation and follow up for evaluation and treatment of the enrollees obesity. Findings:  The physician reviewer found that Based on the clinical documentation submitted for review, a nutrition evaluation and follow up is clinically indicated for this patient. Childhood obesity is a growing problem with significant implications for future health issues. Impaired glucose tolerance is of major concern in overweight children. In addition, obesity is associated with risk factors for cardiovascular disease, including development of atherosclerotic lesions. Hannon and colleagues noted that obesity is the most important risk factor for the development of type 2 diabetes mellitus (T2DM) in youthincreasing rates of T2DM among children and adolescents will have considerable long-term implications for the affected individuals, society, and the public health system as a whole. The authors reported that in addition to their impact on physical well-being, the economic, social, and psychological impact of these conditions is enormous. In this case, the patient presents with a longstanding history of obesity and is beginning to experience chronic complications due to the patients weight, including joint pains, mild hypertriglyceridemia and hypertension. The patients provider has documented discussion about diet and exercise at each visit. When chronic conditions are multifactorial, more involved interventions and education may be necessary. The direct supervision of a nutritionist, whose expertise is in guidance toward healthy diet and lifestyle choices, is medically reasonable and appropriate. Because of the potential for significant complications such as hypertension, obstructive sleep apnea, and diabetes, expert intervention is critical. As such, the request for a nutrition evaluation and follow up have been established as medically necessary for evaluation and treatment of the patients medical condition. Final Result: The reviewer determined that the requested services are medically necessary for evaluation and treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in pediatrics and pediatric critical care 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.