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

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for residential treatment center (RTC) services. Per the American Society of Addiction Medicine (ASAM) criteria, this patient meets Level 3.5 criteria for Clinically Managed High-Intensity Residential Services. ASAM criteria focuses on six dimensions to determine the appropriate level of care including: (1) intoxication and withdrawal potential; (2) biomedical conditions; (3) emotional, behavioral and cognitive conditions; (4) readiness to change; (5) relapse, continued use, or continued problem potential; and (6) recovery environment. Applying the ASAM guidelines, this patient meets the criteria for RTC level of care services. The patient has demonstrated mild to moderate withdrawal symptoms per Clinical Opiate Withdrawal Scale (COWS) scoring. The patient also has biomedical conditions including hepatitis C and prior myocardial infarction. The patients behavioral issues include depression, anxiety and post-traumatic stress disorder (PTSD). The patient has shown a willingness to change, but he continues to report cravings and demonstrates impulsive behaviors. The patient remains at high risk for relapse as he demonstrates impulsivity and reports being unable to control his behaviors. The patients recovery environment is not stable and his peers continue to use substances. The patient requires a safe and stable living environment in order to develop his recovery skills. He thus qualifies for ASAM Level III treatment, similar to what the patient has received at the current RTC facility. Given the severity of the patients illness, the RTC level of care services were and are medically necessary for treatment of this patient. 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 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.
Appeal type: Experimental/Investigational
Decision: Overturned

A 76-year-old male enrollee has requested gamma knife surgery for treatment of his metastatic melanoma to the brain.  Findings:  Two physician reviewers found that the requested services, stereotactic radiosurgery (SRS) is likely to be more effective for this patient than other available options. The use of SRS in the post-operative setting for brain metastases is considered the standard of care. The National Comprehensive Cancer Network (NCCN) guidelines state that radiosurgery is a treatment option for patients with a resected brain metastasis. Retrospective reviews have also demonstrated that radiosurgery in this setting is associated with low local recurrence rates and comparable survival to other treatments such as whole brain radiation therapy (Ogiwara, et al; Karlovits, et al). In this case, the patients most recent medical records indicate that he has an adequate performance status and has recovered appropriately from his emergent neurosurgical operation. Therefore, the use of gamma knife radiosurgery is likely to be more beneficial for the treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

An enrollee has requested authorization and coverage for multi-level lumbar fusion surgery. In this case, the patient presents with persistent grade low back pain radiating into the right leg with weakness and recent episodes of urinary incontinence. The patients records reflect that she has functional limitations in standing, walking, and performing activities of daily living. Clinical exam findings have documented motor weakness. X-ray findings have documented haloing of the S1 screws consistent with loosening, plausible pseudoarthrosis and spondylolisthesis. Imaging findings showed significant foraminal and lateral recess stenosis. Evidence of long-term reasonable and/or comprehensive non-operative treatment and failure has been submitted. Current evidence based medical literature supports revision fusion to treat the patients reported hardware loosening and plausible pseudoarthrosis. Fusion for adjacent segment disease is supported by the patients current spondylolisthesis, surgery adjacent to fusion, and for anticipated temporary intraoperative instability due to the reasonable need for wide decompression. Under these circumstances, the requested multi-level lumbar fusion surgery is medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested digital breast tomosynthesis for evaluation of the enrollee, who was asymptomatic. Findings: Two physician reviewers found that the current medical evidence supports the service at issue in this clinical setting.  Breast tomosynthesis provides advantages to radiologists.  This tomographic method allows the reader to separate dense glandular elements from underlying mass/architectural distortion, resulting in a decrease in callbacks and increase in overall diagnostic accuracy and detection of small cancers compared to two-dimensional imaging alone. Thus, the addition of breast tomosynthesis to the usual two-dimensional protocol was likely of greater benefit to the patient than had her examination been done with two-dimensional imaging alone.Final Result: Two reviewers determined that the service at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: All three physician reviewers are board certified in diagnostic radiology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

A 62-year-old male enrollee has requested coverage for growth hormone (GH) therapy for treatment of his non-Hodgkins lymphoma.Findings:  Three physician reviewers found that the use of human growth hormone to increase the yield of stem cells in patients who have inadequate response to Neupogen or Leukine is investigational. However, there is one paper published in the journal Blood which documents the efficacy of this approach in 16 patients. Although the data is limited, growth hormone therapy does appear to be more promising that conventional therapy at this juncture.
Appeal type: Experimental/Investigational
Decision: Upheld

A 19-year-old male enrollee requested parasympathetic function and sympathetic function heart rate test (CPT 95943) for medical evaluation of his medical condition.  Findings:  Three physician reviewers found that this patient was diagnosed with mild obstructive sleep apnea syndrome.  The etiology of obstructive sleep apnea involves both structural and nonstructural factors, including genetic factors.  The submitted documentation does not demonstrate the indication for the services at issue.  In sum, parasympathetic function and sympathetic function heart rate test was not likely to have been more effective than other options for the evaluation of this patient.
Appeal type: Medical Necessity
Decision: Upheld

A 46-year-old female enrollee has requested an MRI of the left leg for evaluation of her left knee pain. Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the service requested. The documentation submitted for review lacks the requesting providers supporting rationale for the requested imaging study and does not evidence sufficient objective findings of significant symptomatology to support the requested MRI. Moreover, the submitted documentation does not include detailed physical exam notes, documentation of objective functional deficits, or exhaustion of lower levels of conservative treatment or x-ray of the left knee. Given the reasons provided above, the request for an MRI of the left knee is not medically necessary for evaluation of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary:   An enrollee has requested the Prostatic Urethral Lift for treatment of his benign prostatic hyperplasia (BPH).  Two physician reviewers found that although UroLift received U.S. Food and Drug Administration (FDA) approval, long-term studies and comparative studies with transurethral resection of the prostate (TURP) have not been completed. It is unlikely that the UroLift procedure will provide sufficient relief in this patient with such severe obstruction. All told, the requested Prostatic Urethral Lift is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.  Final Result: Two 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: The reviewer is board certified in urology 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 anesthesia services provided during a colonoscopy for treatment of her medical condition. Findings:  The physician reviewer found that monitored anesthesia care was not medically necessary for the patients colonoscopy. The patient did not present with a significant history that would require monitored anesthesia care. The standard of care provides for the use of monitored anesthesia care for minimally invasive procedures if the patient presents with one of the following conditions: airway difficulty, large fluid shifts or co-morbid conditions that put the patient at risk during the procedure. Upon review of the patients medical records, the patient did not meet the criteria for monitored anesthesia care. Procedures like colonoscopy are relatively non-invasive and of short duration; therefore, for some patients, these procedures are well suited to office-based practice. Per American Society of Anesthesiologists (ASA) guidelines, colonoscopy procedures may be safely and effectively performed with conscious sedation of benzodiazepine alone or with a narcotic in an office-based setting without the need of monitored anesthesia care with propofol. A systematic review of randomized controlled trials to compare efficacy, safety, and efficiency of agents used for moderate sedation in colonoscopy concluded that when moderate sedation is utilized, there is a high level of physician and patient satisfaction while providing low risk of serious adverse events with all currently available agents. In sum, anesthesia services during the patients colonoscopy was not medically necessary for treatment of the patients medical condition.  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 anesthesiology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 40-year-old female enrollee requested authorization and coverage of gastric bypass  surgery for the treatment of morbid obesity.  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 surgery is not likely to be more beneficial for treatment of the enrollees morbid obesity 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: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for the medication Acthar Gel. Findings: Research has performed a case review of five patients with refractory dermatomyositis and polymyositis who experienced a disease exacerbation and either failed or were unable to tolerate the side effects of previous therapy with steroids, intravenous immunoglobulins, and steroid-sparing drugs. Other researchers noted that although anecdotal reports suggested that Acthar Gel could be considered as a therapeutic option, further investigation was warranted. Given that current medical literature does not support the use of Acthar Gel in treating refractory polymyositis or in replacing the use of steroids for the treatment of polymyositis, the requested medication is not medically indicated. Therefore, the medication Acthar Gel is not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in rheumatology 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 33-year-old female enrollee has requested gastric bypass surgery for the treatment of her obesity. Findings:  The physician reviewer found that the National Institute of Healths medical necessity criteria require evidence of significant obesity-related comorbidities for consideration of weight loss surgery with a BMI between 35 and 40. This patients BMI is approximately 35. Although there are reported symptoms of severe gastroesophageal reflux disease (GERD), there is marked disparity between the endoscopic findings and pathology findings (normal lower esophagus). A diagnosis of severe GERD is not supported and minimal symptoms can be effectively managed with over-the-counter medications. The patient also had a normal sleep study. Although gastric bypass surgery may be considered definitive therapy for intractable GERD, the record does not indicate that surgical intervention is warranted. Should additional objective studies such as upper GI series, esophageal manometry and 24-hour pH monitoring (off PPIs) support a diagnosis of severe GERD, then the appropriateness of gastric bypass surgery should be reassessed. Unequivocal psychological clearance would also need to be assured.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a 14-year-old male enrollee has requested mental health services for treatment of the enrollees schizophrenia and ADHD.  Findings:  The physician reviewer found the records indicate that during the acute hospital stay, the patient was cooperative and appeared at his baseline. No medication changes were made. He did receive some cognitive behavioral therapy. Although the patient should not be in the home with his six-year-old sister, he did not need treatment at the inpatient level of care. He did not and does not require 24-hour nursing or medical care. He could have been transferred to emergency placement and continued cognitive behavioral therapy on an outpatient basis. Overall, the records provided for review do not support the medical necessity of the mental health services for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a 15-year-old female enrollee has requested reimplantation of teeth #23 and #26 coded as CPT 41899   for treatment of the enrollee, who is status post traumatic injury.  Findings:  The physician reviewer found that from the notes and photocopies of photographs provided, the patient did sustain significant dental trauma, including fracture of her anterior mandibular alveolar process. Her alveolar fracture needed to be reduced and fixated in order to salvage the teeth and allow the alveolar process to heal. The successful treatment of the alveolar fracture is based on proper reduction and repositioning of the fractured segments and associated teeth. Given that the teeth were present and already involved with the fracture, treatment of the fracture would involve repositioning and stabilizing the teeth. Thus, reimplantation of teeth #23 and #26 coded as CPT 41899 was not medically indicated, as the teeth would have been repositioned with the treatment of the fracture. All told, the submitted documentation does not demonstrate the medical necessity of the services at issue.
Appeal type: Medical Necessity
Decision: Upheld

A 49-year-old male enrollee requested authorization and coverage of Cyberknife therapy. The Health Plan denied the request indicating that the requested therapy is not medically necessary for treatment of the enrollees chordoma.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested therapy is not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent male enrollee has requested reimbursement for residential treatment center (RTC) services. The American Academy of Child and Adolescent Psychiatrys (AACAP) Child and Adolescent Service Intensity Instrument (CASII) was developed to help determine the appropriate level of service intensity for behavioral health treatment for youth. The CASII utilizes dimensions that are relevant to the patients clinical status when determining appropriate level of service intensity. These dimensions include risk of harm, functional status, co-occurrence, environmental stress, environmental support, resiliency and/or response to services, patient involvement in services, and parent involvement in services. Based on the patients clinical history provided and documentation as outlined above, the patient met CASII criteria for non-secure 24-hour psychiatric monitoring. The patient remained symptomatic throughout his admission. He was noted to be depressed, anxious, and irritable. He had documented incidents of yelling, cursing and physical aggression towards staff and inappropriate behaviors toward his peers. Due to the patients persistence of symptoms, he had changes in his medication regimen to target these symptoms including trials of buspirone, duloxetine, and aripiprazole. The patients clinical status, in addition to current medical literature, support that the treatment at the residential level of care was appropriate for this patient. For these reasons, the RTC services provided were medically necessary for treatment of this patients behavioral health issues. 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 with sub-specialty 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: Upheld

The parent of a four-year-old male enrollee has requested group social skills training twice per week for treatment of the enrollees autism. Findings:  The physician reviewer found that successful performance in an organized school program will require some development of prerequisite social skills. Thus, it is important that the patient be introduced to socializing and interacting with his peers. Myers, et al. states that a social skills curriculum should target responding to the social overtures of other children and adults, initiating social behavior, minimizing stereotyped perseverative behavior while using a flexible and varied repertoire of responses, and self-managing new and established skills. Reichow and colleagues performed a Cochrane systematic review of five randomized controlled trials which when combined suggest that there is evidence that social skills group therapy can improve social competence for children with autism spectrum disorders. While the above evidence demonstrates the importance of socials skills therapy, the patient is currently receiving ABA therapy and his current ABA treatment plan includes social skills and group skills development. As such, two weekly sessions of group social skills therapy in addition to the patients current ABA therapy regimen is not medically necessary.