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

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for endovascular stent repair procedure with a one-day inpatient stay.According to researchers, Complex AAAs have traditionally been treated with an open surgical repair (OSR). During the past decade, fenestrated endovascular aneurysm repair (FEVAR) has emerged as a viable option. The authors found, FEVAR was associated with lower perioperative morbidity and mortality compared with OSR for the management of complex AAAs. Moreover, researchers also found that with OSR, the odds for major complications, minor complications, and short-term mortality were significantly higher compared with complex endovascular aneurysm repair.In this case, the patient has a large AAA at risk for rupture. Based on the CTA report, the AAA was 6 centimeters in diameter. Additionally, the risk of rupture is heightened by severe, difficult to control hypertension and chronic back pain. As back pain is a common symptom of aneurysm rupture or impending rupture, it creates a potentially untenable situation to attempt to manage an AAA in a patient with chronic back pain conservatively. Due to the patients considerable comorbidities and the need to control the aorta suprarenal, an endovascular approach is medically necessary. It is also medically necessary to perform the repair with a device that would successfully exclude the aneurysm. Depending on the patients condition after the procedure, an inpatient hospital stay is reasonable and medically necessary. Therefore, the requested endovascular stent repair procedure with a one-day inpatient stay is medically necessary for treatment of the patients medical condition.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 vascular 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: Upheld

The patient is a 52-year-old male who has a history of long-standing migraine headaches who has been treated with a large number of medications that have not provided the necessary relief. Some of the patients medications suggest comorbid problems such as low back pain, depression, and insomnia. The patient would like to obtain 27 Imitrex 100mg tablets per month for his migraine headaches. The Health Plan has determined the requested prescription is not medically necessary for treatment of the patients medical condition.Upon review of the consultation reports by his neurologists, it appears that the patient suffers from rebound headaches. This condition is frequently noted in patients who take large quantities of medications aimed at the acute treatment of migraine headaches. Further attempts at prophylactic headache treatment are medically indicated and likely to be more effective than the patients current regimen. Other non-pharmacological modalities such as stress reduction, cognitive therapy, and behavioral therapy may also be indicated since the patient experiences migraines and depression. Continued overuse of Imitrex is contraindicated. Therefore, I have determined the requested prescription is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: This patient has a history of sleep apnea, gastroesophageal reflux disease (GERD), and degenerative joint disease (DJD). A psychological evaluation was obtained on 8/15/17 and did not reveal any obvious barriers to surgery.  A dietary evaluation was obtained on 1/22/18 and did not reveal any obvious barriers to surgery. A sleep study was performed on 1/15/19 and revealed moderate obstructive sleep apnea hypopnea with an apnea hypopnea index (AHI) of 22.3.  Progress notes dated 3/20/19 reported the patient is 64 inches tall and weighed 217 pounds, resulting in a body mass index (BMI) of 37.25 kg/m2. There is no medication for hypertension noted. The patient has requested authorization and coverage for laparoscopic sleeve gastrectomy. At issue in this case is whether laparoscopic sleeve gastrectomy is medically necessary for treatment of the patients medical condition.There is sufficient support for the requested services in this clinical setting. Researchers noted Obesity continues to be a major public health problem in the United States, with more than one-third of adults considered obese in 2009-2010, as defined by a BMI greater than or equal to 30 kg/m2. Nonsurgical management can effectively induce 5%-10% weight loss and improve health in severely obese individuals resulting in cardio-metabolic benefit. Bariatric surgery procedures are indicated for patients with clinically severe obesity. This patient has a BMI of 37 kg/m2 and history of GERD and DJD. The records document sleep apnea with AHI of 22.3, indicating moderate sleep apnea consistent with a diagnosis of morbid obesity.  She completed a thorough multidisciplinary evaluation that did not reveal any obvious dietary, medical or behavioral barriers to surgery. The patient has failed dietary efforts at weight loss with her primary care provider.  Therefore, she meets standard nationally accepted criteria for bariatric surgery, including the American Society for Metabolic and Bariatric Surgery (ASMBS) guidelines.  Therefore, the requested laparoscopic sleeve gastrectomy 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 general surgery with expertise in bariatric surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

A 48-year-old female enrollee has requested for transcranial magnetic stimulation (TMS) for treatment of her major depressive disorder.   Findings:  Two physician reviewers found that the FDA has approved TMS as a specific treatment for severe depression and gives guidelines for its use. Additionally, the American Psychiatric Association (APA) included TMS in their 2010 guidelines as an appropriate acute phase treatment option for patients who do not respond adequately to medication therapy. Further, the American Medical Association (AMA) has approved Category I CPT codes for TMS effective in January 2011. Several articles are cited from the literature that shows that TMS compares favorably with ECT. Grunhaus and colleagues reported that their conclusion is particularly relevant because it suggests that rTMS and ECT reach similar results in nonpsychotic major depressive disorder. Similarly, Eranti and colleagues noted that although ECT was more effective in the short term, at 6 months the HAM-D scores did not differ between groups. Self- and observer-rated cognitive measures were similar in the two groups. This patient has been treated with multiple available standard therapies without improvement in symptoms. Consistent with this clinical support, the requested TMS therapy is likely to be beneficial than other standard therapies available to this patient.
Appeal type: Medical Necessity
Decision: Upheld

This patient is a 47-year-old female with chronic Hepatitis C that has either not completely responded or relapsed following two prior one-year treatments with interferon-ribavirin therapy.  Her previous therapy was continued until October 2004 and she had detectable viral load in January 2005; three months later.  End-of-treatment titers were not provided.  The patient is requesting a third treatment with a third different interferon. Her symptoms are minimal according to her chart notes, hepatic enzymes are only slightly elevated, hepatic synthetic function is preserved and a biopsy performed in April 2005 shows minimal hepatic disease.  The Health Plan denied authorization for the Infergen and Copegus therapy on the basis that it is not medically necessary or likely to be effective.The patient has failed two standard therapies for Hepatitis C and should not receive further therapy until there is a therapy available that offers a reasonable likelihood of success for previous non-responders or early relapsers.  As yet, no such therapy has been discovered or adequately tested in carefully controlled trials.  The patients minimal symptoms, hepatic enzyme abnormalities and histological changes indicate that either she may not need treatment or that she has the ability to wait for further therapy until a one with proven efficacy for patients such as herself is available. Therefore, I have determined the requested therapy is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested breast tomosynthesis for evaluation of her medical condition.  Findings:  Two physician reviewers found that breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than available standard modalities. The American College of Radiology (ACR) statement on breast tomosynthesis has urged tomosynthesis be removed from an investigational category due to its utility in breast imaging. The advantage the technique offers is the ability of the provider to separate dense glandular tissue from mass/architectural distortion. There has been worldwide support for the tomosynthesis by providers due to an associated decrease in callbacks and increase in detection of small cancers.  For this reason, the use of tomosynthesis in this particular patient was likely of more benefit than if the mammographic views had been done with two-dimensional imaging only. Final Result: Two  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: 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: Overturned

The parent of an eight-year-old male has requested one-to-one applied behavioral analysis (ABA) therapy at a frequency of 20 hours per week for treatment of his autism.  Findings:  The physician reviewer found that studies have been conducted looking at low intensity (less than 20 hours per week) and high intensity (greater than 20 hours per week) of ABA therapy in young patients with autism. In addition, studies have been conducted looking at intensive ABA therapy versus standardized care. Comparing patients that received ABA therapy with those who received standardized therapy, there is a clear statistical improvement in cognitive, language and adaptive behavior skills. A study included in Spreckley and Boyds meta-analysis states that a non-systematic review concluded that for best practice a minimum of 20 hours a week of intervention over two years, taking account of each patients strengths and weaknesses and family circumstances, is essential for young children with autism to make gains. Eikeseth noted in a study that children who received ABA therapy made significant gain compared to those who were in special education. On average, the children who received the ABA treatment gained 17 IQ points, 13 points in language comprehension, 23 points in expressive language, and 11 points in adaptive behaviors. In comparison, the eclectic treatment group obtained an average of +4 points in IQ, 1 point in language comprehension, 2 points in expressive language and zero point in adaptive behaviors. The American Academy of Neurology and Child Neurology Society guidelines for treatment developed in 2000 states that, The immediate and long-term evaluation and monitoring of autistic individuals requires a comprehensive multidisciplinary approach, and can include one or more of the following professionals: psychologists, neurologists, speech-language pathologists and audiologists, pediatricians, child psychiatrists, occupational therapists, and physical therapists, as well as educators and special educators. The article by Sallows and Graupner shows the benefit of ABA and this has been replicated by others in the peer reviewed journals as well. In the report by this patients provider, it was noted that the patient is impulsive and would grab a scissor or knife and this is potentially injurious to others or himself. ABA therapy is not only for the developmentally inappropriate behavior but also to help redirect and reward positive behaviors. Consistent with these findings, the requested service of ABA is supported as medically necessary at the frequency of 20 hours per week.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential treatment care from 12/6/16 through 12/13/16. Findings:  The physician reviewer found that there is a lack of support for the services at issue in this clinical setting. By 12/6/16, the records indicate that the patient was no longer a danger to himself or to others. He was not gravely disabled.  He was no longer psychotic.  The patient was cognitively intact and performing activities of daily living. He did not demonstrate a high degree of impulsivity or manic/hypomanic behavior. He was medication compliant.  He had no comorbid medical conditions.  He was psychiatrically stable to the point that he no longer required the confines of a residential setting.  His medications did not require monitoring at the residential level. He was at risk in terms of substance abuse, as evidenced by his declaration that he had no desire to maintain sobriety. However, his home environment was supportive of both his substance abuse recovery and his psychiatric illness. This patient could have continued his treatment at a lower level of care. 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 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 38-year-old male enrollee has requested for a blood glucose monitor for treatment of his pre-diabetic condition.  Findings:  The physician reviewer found that criteria for a diagnosis of diabetes are found in the American Diabetes Association (ADA) and American Association of Clinical Endocrinologists (AACE) guidelines. A fasting glucose of 112 mg/dl is considered pre-diabetes. However, a two-hour glucose tolerance test is the standard test to determine this diagnosis.
Appeal type: Experimental/Investigational
Decision: Upheld

A 51-year-old female enrollee has requested genetic testing (BRCA 1 and BRCA 2) for evaluation of her risk for breast cancer.  Findings:  Three physician reviewers found that BRCA is recommended for certain women of Ashkenazi Jewish descent (who do not themselves have cancer) if there is a first-degree relative (or two second degree relatives on the same side of the family) with breast or ovarian cancer. For women of non-Ashkenazi Jewish descent, there needs to be a strong history of breast and/or ovarian cancer in a patients family for BRCA genetic testing to be indicated. This patient is of Ashkenazi Jewish descent but does not meet the criteria for testing of women of Ashkenazi Jewish descent. Therefore, there is no support for the genetic testing at issue in this case.
Appeal type: Medical Necessity
Decision: Upheld

The parents of a three-year-old male enrollee requested authorization and coverage for an adaptive toilet chair and a referral to pediatric neurologist. The Health Plan has denied this request indicating that the requested equipment and referral are not medically necessary for treatment of the enrollees congenital hypotonia.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested referral and equipment are not medically necessary.
Appeal type: Experimental/Investigational
Decision: Overturned

An 18-year-old male enrollee has requested a CT angiography for evaluation of his chest pain and dyspnea on exertion.  Findings:  Two physician reviewers found that CT coronary angiography is an acceptable alternative to coronary angiography in excluding anomalous coronary origins, and is often performed as a confirmatory test after a non-diagnostic angiography to define the origin and relationship to the great vessels in suspected cases.  According to the 2006 Appropriateness Criteria referenced above, the use of coronary CT angiography for evaluation of suspected coronary anomalies is highly appropriate (highest score 9/9) for this indication.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested for occupational therapy, (with a portion being sensory integration therapy) for treatment of the enrollees medical condition.  Findings:  The physician reviewer found that review of the submitted documentation and relevant literature demonstrates the medical necessity of the requested therapy. According to the documentation submitted for review, the patient continues to require treatment for her fine motor skills. It is likely she will meet these goals soon. In addition, the patient also has sensory integration goals. Researchers examined the effectiveness of Ayres Sensory Integration (ASI) and sensory-based interventions within the scope of occupational therapy for patients with autism spectrum disorder to improve performance in daily life activities. They found that the ASI intervention had moderate level of good quality research to indicate this can be recommended for children with autism spectrum disorder. In addition, researchers also found that sensory integration interventions can improve daily living skill attainment. They also reported better engagement in the classroom with frequent physical activity breaks. Overall there is evidence that sensory based interventions are effective for helping children with autism spectrum disorder with self-regulation, tolerating noisy environments and improving oral motor sensory issues.  Although the patient has made improvements in many areas, she still has difficulty with sensory issues and she still requires occupational therapy, including sensory integration therapy. Based upon the documentation provided, the medical necessity for occupational therapy (with a portion being sensory integration therapy) has been established.  Final Result: The reviewer determined that the requested therapy 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 pediatrics with sub-specialty certification in developmental and behavioral pediatrics 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 Orthovisc injections to the bilateral knees for treatment of her knee pain.  Findings:  The physician reviewer found that evidence based medical peer-reviewed literature supports the use of repeat series of viscosupplementation injections for the treatment of pain in patients with osteoarthritis of the knee. This has been found to be safe and effective and allows for delay of total knee replacement. Bannuru and 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. Pagnano and Westrich conducted a systematic review on the efficacy and safety of repeat courses of hyaluronan therapy in patients with osteoarthritis of the knee and concluded that repeat courses of the hyaluronan were safe and effective in the treatment of pain associated with osteoarthritis of the knee. Turajane and colleagues concluded that repeated cycles of intra-articular sodium hyaluronate treatment to delay time to total knee replacement in patients with knee osteoarthritis which failed conservative treatment was found efficacious during a 54-month follow-up period. In this case, the patient has been diagnosed with severe osteoarthritis of both knees. The patient has been diagnosed with bilateral knee end-stage degenerative joint disease. She has undergone two prior viscosupplementation series with long-term pain reduction documented and has had the ability to avoid surgery. She has failed to respond to other conservative treatment including anti-inflammatory medications, physical therapy, activity modification, and corticosteroid injections. For all these reasons stated above, the requested Orthovisc injections for both knees are medically necessary for treatment of the patients bilateral knee pain. Final Result: The reviewer determined that the requested therapy 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.