Persius/imr-appeals huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Upheld

A 53-year-old male enrollee requested authorization and coverage of a Stretta procedure. The Health Plan denied the request indicating that the requested procedure is considered experimental for the treatment of the enrollees gastroesophageal reflux disease (GERD).Three physician reviewers performed a medical necessity Independent Medical Review. Two physician reviewers concluded that the requested procedure is not likely to be more beneficial for the treatment of the enrollee's medical condition than any available standard therapy. One physician reviewer concluded that the requested procedure is likely to be more beneficial for the treatment of the enrollee's medical condition than any available standard therapy. Because two of the three physician reviewers concluded that the requested procedure is not likely to be more beneficial for the treatment of the enrollee's medical condition than any available standard therapy, the Health Plans denial has been upheld.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a 16-year-old female enrollee has requested  for psychiatric residential treatment for treatment of her generalized anxiety disorder, depressive disorder, not otherwise specified, and non-verbal learning disorder. Findings:  The physician reviewer found that that the patient has several psychiatric issues, including anxiety, a learning disorder and limited depression, it does not suggest that she was homicidal, overtly suicidal or psychotic at any time. At the time of the psychiatric evaluation, she was not manifesting behaviors indicating a current deterioration in mental functioning.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for outpatient cardiac rehabilitation (CPT 93798).Traditionally, formal cardiac rehabilitation/structured exercise plan has been reserved for patients with established coronary artery disease, prior revascularization, peripheral vascular disease or congestive heart failure. Recent published data, guidelines and expert opinions have focused on the use of exercise training to improve overall cardiovascular function, slow resting heart rates and decrease the life-limiting symptomatology associated with POTS and inappropriate sinus tachycardia syndromes. The psychological component of this syndrome and fear of exercise inducing further symptoms often leads to cardiovascular deconditioning. It is also often improved when an initially supine/sitting, structured exercise program is gradually instituted. Given the published data, expert opinion, and Heart Rhythm Society guidelines, outpatient cardiac rehabilitation can improve cardiac conditioning, decrease symptoms, and improve psychological factors. In this case, the patient continues to have life-limiting symptoms despite lifestyle management. There is sufficient support for the requested services in this clinical setting. Therefore, outpatient cardiac rehabilitation (CPT 93798) is medically necessary for the treatment of 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 internal medicine with sub-specialty certification in cardiovascular disease 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

This patient is a six-year-old male who was diagnosed in 2002 with autism. He received weekly social skills group therapy from January 2003 to June 2004, which was covered by the Health Plan. Since September 2004 the patient has been receiving social skills group therapy through Developmental Pathways for Kids. The patients parents have requested authorization and coverage for social skills group therapy. The Health Plan has denied the request on the basis the requested therapy is not medically necessary for treatment of the patients medical condition. In reviewing the submitted literature, the specific therapy concept as developed by Dr. Wolfberg is supported by retrospective or case-control studies that are of small scale, one of which was a masters thesis presentation. None of the articles provided demonstrate social skills group therapy for autism is equal or superior to standard therapy or educational training. Additionally, these therapies have historically been included as part of the students school curriculum through the IEP program. As such, the alternative recommended by the Health Plan is an acceptable alternative and is appropriate for treatment of the patients condition. Therefore, I have determined the requested therapy is not medically necessary. The Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for computer-assisted navigation (CPT 20985) for the approved right total knee replacement procedure. Computer-assisted navigation techniques are classified as either open or closed systems. Computer mapping is created with pre-operative imaging via computed tomography (CT) or magnetic resonance imaging (MRI), intraoperative imaging with modified fluoroscopy, or an image-free technique using a surface probe. Clinical practice guidelines do not recommend computer-assisted navigation, since short- and long-term follow-up data have shown no differences in multiple outcome measures. Computer-assisted navigation is not recommended for routine knee arthroplasty and is reserved for patients with significant femoral bony deformity, where conventional intramedullary alignment lacks accuracy. There is insufficient evidence to support computer-assisted navigation for orthopedic surgery in lieu of conventional methods. In this case, the patient is presents with end-stage right knee osteoarthritis and substantial symptoms. However, the submitted medical records do not document the presence of significant bony deformity or other exceptional factors, which would justify computer-assisted navigation. Therefore, the requested computer-assisted navigation (CPT 20985) for the approved right total knee replacement procedure 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 computer-assisted navigation (CPT 20985) for the approved right total knee replacement procedure 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 orthopedic surgery 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: Overturned

Nature of Statutory Criteria/Case Summary: The patients parent has requested reimbursement and prospective authorization and coverage for IOP services provided by Center for Discovery Sherman Oaks. The Child and Adolescent Level of Care Utilization System (CALOCUS) provides a framework for determining the clinically appropriate level of care for a child or adolescent in mental health treatment. With regard to risk of harm, the records support a score of 3. The patient had risk of harm, due to passive suicidal ideation and homicidal ideation without plan or intent. In terms of functional status, the records support a score of 3. The documentation noted that the patient reported feeling overwhelmed by school and had issues with focus and concentration.With regard to comorbidity, the records support a score of 1. The patient had no significant comorbidity, due to medical, substance use or developmental disability. In terms of level of stress of the recovery environment, the records support a score of 4. The patient had a stressful environment due to ongoing feelings of being overwhelmed by school, and continued to have nightmares secondary to trauma.With regard to level of support of the recovery environment, the records support a score of 2 due to parental engagement in family therapy. In terms of resiliency and treatment history, the records support a score of 3. The patient had poor resiliency and/or response to treatment as previous individual outpatient therapy and medication management had not ameliorated anxiety, depression, and PTSD symptoms and suicidal ideation.With regard to treatment acceptance and engagement, the records support a score of 2. The patient had recently begun to act on constructive feedback instead of withdrawing and shutting down. Thus, the patient has a total score of 18. In this case, the recommended level of care was high intensity community-based services or IOP. Therefore, IOP services provided by Center for Discovery Sherman Oaks were and are medically necessary for the 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 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 patient is a five-year-old male with a diagnosis of autism since the age of two. He has been receiving speech therapy since 2003. He has been receiving twice a week therapy from Rainbow Kids Achievement Center and once a week therapy from a private therapist since October 2003. At issue in this case is the therapy the patient received from Rainbow Kids Achievement Center from 10/10/04 to 2/10/05.Although the information provided shows some improvement in the patients speech under the regimen described above, there is no level-one evidence supporting the frequency of this patients therapy, especially given that it was individual therapy. Furthermore, the primary goals for this patient were articulation and comprehension, which are generally considered educational and not medical in nature. In fact, evidence suggests this patients needs and goals would be better served in a group setting. There is no evidence demonstrating twice a week individual speech therapy from 10/10/04 to 2/10/05 was medically necessary for this patient. Therefore, I have determined the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

A 58-year-old female has requested coverage for bilateral salpingo-oophorectomy for treatment of her breast cancer.  Findings:  The physician reviewer found that currently, there are no guidelines supporting ovarian ablation in post-menopausal female patients with hormone receptor positive breast cancer. The National Comprehensive Cancer Network (NCCN) practice guidelines do not recommend the requested bilateral salpingo-oophorectomy in this patients clinical situation. Given the lack of data supporting the medical necessity of the bilateral salpingo-oophorectomy in this patients care, the requested surgery is not supported as medically necessary for treatment of her medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for fertility preservation services (ovarian stimulation, oocyte retrieval, oocyte fertilization and storage of oocytes and/or embryos) for treatment of the enrollees risk of iatrogenic infertility due to treatment for breast cancer. Findings:  The physician reviewer found that Successful cancer treatment in younger patients often leads to reduced fertility. If the cancer treatment can be delayed, it is possible to undergo ovarian stimulation and retrieve and freeze eggs (both mature and immature) or produce embryos that can be frozen for later transfer to the individual or a gestational carrier. The American Society for Reproductive Medicine (ASRM) indicates that the established strategy for preservation of female fertility is for a woman to undergo a cycle of in vitro fertilization (IVF) and create embryos for later use. The ASRM also noted that the established methods of fertility preservation include sperm cryopreservation in men and embryo and oocyte cryopreservation in women. Patients with breast cancer undergoing initial treatment with lumpectomy or mastectomy often will have an interval of time available to them for an oocyte retrieval prior to initiating postoperative chemotherapy. Oocyte and embryo preservation are therefore considered a standard of care for fertility preservation in patients about to undergo breast cancer treatments. Given this support, the requested fertility preservation services (ovarian stimulation, oocyte retrieval, oocyte fertilization and storage of oocytes and/or embryos) was and is medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the services at issue were and are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in obstetrics and gynecology with sub-specialty certification in reproductive endocrinology 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 Valtrex for treatment of the enrollees viral infection. Findings: The physician reviewer found that there is a lack of support for the requested medication in this clinical setting.  The patient reported chronic fatigue.  The laboratory studies were significant for an elevated Epstein-Barr virus and a borderline high cytomegalovirus level.  The plan of care was to treat for a viral infection with valacyclovir.  Per the patient, generic valacyclovir is made in a factory that contains gluten products while Valtrex is made in a gluten free factory.  The documentation provided does not describe gluten intolerance or any significant food allergies.  There is no documentation that the patient is allergic to gluten or has a diagnosis of celiac disease.  When a generic drug product is approved by the U.S. Food and Drug Administration (FDA), it has met rigorous standards established by the FDA with respect to identity, strength, quality, purity and potency.  Generic drugs are required to have the same active ingredient, strength, dosage form and route of administration as the brand name product.  In this case, there is insufficient documentation indicating that the patient has had a significant adverse reaction to the generic drug, valacyclovir.  Furthermore, the mainstay of treatment for patients with infectious mononucleosis and other manifestations of primary Epstein-Barr virus disease is supportive care.  Acetaminophen or nonsteroidal anti-inflammatory drugs are recommended for the treatment of fever, throat discomfort, and malaise.  All told, Valtrex is not medically indicated 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 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: The parent of an enrollee has requested reimbursement for the residential treatment center (RTC) services. Applying the child and adolescent level of care utilization system (CALOCUS), the RTC services provided to this patient were not medically necessary. The patient presented with some risk of harm (score 2) due to the patients history of impulsive actions and aggression. However, the medical records indicate that the patient was not actively suicidal. The patient demonstrated moderate functional impairment (score 3) with some school disruption due to substance use. The patient had mild co-morbidity (score 2) with a history of substance use. The patients recovery environment was mildly stressful (score 2) with a positive recovery environment and a stable housing situation. The patients recovery environment was supportive (score 2) as the patients parents are actively is involved in treatment and often took her on passes. The patient has demonstrated limited positive response to previous treatment (score 3). The patient was noted to be constructive in treatment (score 2) as she participated in therapy and used coping skills learned in therapy. The patients parents were constructive (score 2) as they worked actively and constructively with the patients providers. This gives the patients presentation a composite score of 18, which correlates with intensive outpatient services. This score is judged by the acuity of the patients symptoms and environment during the period under dispute at the RTC. According to the CALOCUS, the patient would need to have a score of 23-28 in order to require treatment in an RTC. In summary, the RTC services provided were not medically necessary. Final Result: The reviewer determined that the services at issue were not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in psychiatry with 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

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for VASER liposuction (suction assisted lipectomy CPT 15879). Researchers noted that, Lipedema is an uncommon disorder characterized by localized adiposity of the lower extremities, often occurring in females with a family history of the condition. The adiposity extends from hips to ankles and is typically unresponsive to weight loss. The authors commented that, One of the major distinguishing features of lipedema is the sparing of the feet, which can create a distinct step-off at the ankle. The records provided for review document that this patient has generalized adiposity, not localized to the lower extremities. The patient has a demonstrated ability to lose a significant amount of weight from 295 pounds to 150 pounds. Her present weight is 260 pounds with a BMI of 42.0 kg/m2. There is a lack of evidence of persistence of fat despite weight loss. She does have a characteristic collection of fat in her lower legs while sparing her feet, but there is no reported functional disability from this finding. Based on peer-reviewed medical literature, the VASER liposuction (suction assisted lipectomy CPT 15879) was not medically necessary for treatment of the patient. While the patient demonstrates obesity with a BMI over 40.0 kg/m2, this is not a result of a congenital defect, a developmental abnormality, trauma, infection, tumor, or disease. The patients condition is not an abnormal structure of the body, rather is a normal structural change that is an accommodative response to gain of body mass. The appearance of the patient is normal and consistent with the gain of weight. There is no report of loss of function due to lipedema and the procedure at issue would not have provided a more than minimal improvement in the patients appearance. Thus, the VASER liposuction (suction assisted lipectomy CPT 15879) was not reconstructive in nature for treatment of this patient. Final Result: The reviewer determined that the services at issue were not medically necessary and not reconstructive in nature for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in plastic 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: Upheld

A 48-year-old male has requested percutaneous discectomy with intradiscal electrothermal annuloplasty (IDET) to L2-3 and L4-5 for treatment of his lumbar spine pain.   Findings:  Three physician reviewers found that the patients chronic low back pain resolved to some extent with opioids and muscle relaxants. However, the patient continues to have pain with inability to sleep. There was no provocation discography or analgesic discography reportedly performed on this patient. Further, facet joint pain has not been ruled out. The provider has recommended percutaneous discectomy with intradiscal electrothermal annuloplasty (IDET) to L2-3, L3-4, and L4-5 disc levels. Based on the available evidence, IDET may be indicated for patients after appropriately assessing discogenic pain with provocation discography. This patients records do not indicate that this has been performed. In addition, the overall effectiveness of IDET has not been proven. The evidence for IDET in recent evaluation was shown to be limited. This patients provider has not performed any type of controlled diagnostic blockade with provocation discography or diagnostic facet joint nerve blocks. Consequently, at this point, it is unknown if this patient has discogenic pain. Further, it is highly unlikely for a patient to improve significantly when more than one level is involved, as in this case.