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

A 45-year-old male enrollee has requested continued transcranial magnetic stimulation (TMS) therapy  for treatment of his major depressive disorder.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  In this patients case, he did not achieve remission despite a course of TMS therapy.  Per the submitted records, the patient required acute hospitalization during his treatment course.  Thus, the requested services are not likely to be an efficacious modality in this setting.  The utility of TMS therapy in long-term or maintenance treatment for major depressive disorder has not been established at this time.  Based upon the clinical records, he responded to unilateral electroconvulsive therapy.  All told, continued TMS therapy is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested has requested reimbursement for fertility preservation services. The patient was at risk of iatrogenic infertility due to treatment for breast cancer. An attempt of fertility preservation, specifically treatments necessary for oocyte retrieval and cryopreservation, is considered medically necessary for this patient since she will be undergoing chemotherapy that may cause irreversible/permanent changes to her reproductive organs that prevent natural childbearing options in the future. The American College of Obstetricians and Gynecologists have determined that oocyte cryopreservation, with appropriate counseling, is recommended for patients facing infertility due to chemotherapy or other gonadotoxic therapies. Per the American Society of Clinical Oncology, it is now standard of care to offer reproductive-aged patients with cancer a fertility preservation consult before administering gonadotoxic therapies. This discussion is crucial because fertility preservation can be accomplished with minimal to no delay in cancer treatment and many cancer treatments decrease fertility. The services in issue in this case include office visits, ultrasound testing, venipuncture, and assays of progesterone and estradiol. In this case, these monitoring and laboratory services were associated with oocyte cryopreservation, and as such, they were medically necessary to prevent iatrogenic infertility. Accordingly, the services in issue were medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the services in 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 obstetrics and gynecology 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 mental health inpatient treatment for treatment of his altered mental status and agitation. The physician reviewer found that dementia is a chronic and progressive disease complex that often demands treatment in specialized facilities in the later stages of the illness. Transient treatment in acute settings, as seen in this case, is also often necessary due to the myriad of biopsychosocial complexities associated with major neurocognitive disorders. In this case, the services at issue were medically necessary. The patient remained engaged in active treatment that was reasonably expected to improve his condition and prevent a more serious episode of illness. The patient remained on one-on-one nursing supervision and required staff assistance with activities of daily living. Further, he was in need of dermatologic consultation and physical therapy assessment, while his medication regimen was up-titrated. Thereafter, the inpatient team optimized the medication regimen, and provided appropriate clinical care and discharge planning services which ultimately resulted in a successful discharge to a suitable facility.  The Health Plan contends that the services provided were custodial in nature, and thus the level of care was not medically necessary. However, the services in dispute could not have been safely and effectively provided by non-health care professionals, and as such, did not qualify as custodial care. Both the clinical care and treatment setting were safe, appropriate and consistent with good medical practice. Thus, the services at issue were medically necessary for treatment of the patients medical condition. 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:  An enrollee has requested authorization and coverage for a power scooter for treatment of the enrollee, who is a T5 paraplegic.  Findings:  The physician reviewer found that power mobility can benefit specific individuals. This patient reported that he would like a power scooter to improve community mobility and lessen the physical demands of manual wheelchair usage which may be impacting his overall wellbeing. This patient has a personal mobility deficit and has safely used a power scooter in the past which improved his level of independent function. A power scooter is medically necessary to achieve the primary goal of spinal cord injury rehabilitation, maximizing the patients independence. Thus, in this patients case, the requested power scooter is medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested equipment 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 physical 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: Overturned

Nature of Statutory Criteria/Case Summary: The enrollee has requested surgery to repair, remove, or replace a hernia mesh implant for treatment of the enrollee who has a history of chronic pain in the abdomen/stomach area. Findings:  The physician reviewer found that this patient has had extensive tests to determine the cause of his abdominal pain. These tests were negative. In the absence of organic findings for abdominal pain on imaging, chronic pain associated with mesh is therefore a possibility.  Other possibilities include irritable bowel syndrome, given that this patients pain is relieved with bowel movements.  However, the gastroenterology consultation did not definitively advise further treatment for this beyond therapy with the medication Xifaxan.  The studies have shown that it possible to develop chronic pain after an inguinal hernia repair. The incidence of chronic pain in such cases has increased over time with the use of hernia mesh.  Additionally, there is evidence that surgical repair of pain associated with a mesh can be effective.  Therefore, the request for surgery to repair, remove, or replace the hernia mesh implant is supported as 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 internal medicine with sub-specialty certification in gastroenterology 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 treatment at an inpatient level of care for treatment of her depression, eating disorder, and anoxic brain injury. The physician reviewer found that this patient is complicated and represents a treatment failure from her residential treatment center program. She also did not tolerate medications well and required medical and nursing supervision to monitor them. She remained suicidal during the period of her treatment. In addition, she remained passively suicidal at the time of discharge. Her affect remained constricted, she was not eating, and she was poorly communicative. These are all risk factors for possible self-harm if not closely monitored. Therefore, the treatment at the inpatient level of care was medically necessary for treatment of this patients medical condition. 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: Upheld

The patient is a three-year-old male with a diagnosis of mild autism spectrum disorder. He has been evaluated by a pediatric neurologist and was referred for occupational therapy (OT). The patient has been receiving OT services from two different providers for several months and is reportedly making progress. The parent has requested continued authorization and coverage for 30 minute sessions of OT provided by Orange County Therapy Services. The Health Plan denied the request based on a determination that OT is not medically necessary for the treatment of the patients sensory processing, motor skills and body awareness deficits.Additional OT services have been requested to address overall sensory processing, feeding (oral motor and sensory processing), fine motor, body awareness, motor planning and postural control. A thorough review of two research data bases reveals no medical evidence that OT intervention to address these issues is effective. Consequently, the therapy cannot be considered 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: The patient has requested reimbursement for neuropsychological testing. The use of imaging studies alone may not be helpful in determining clinical functioning. Neuropsychological testing is a key diagnostic tool for assessing people with mild cognitive impairment and can provide data on different cognitive domains as well as neuropsychiatric and behavioral features. Baseline neurological testing can establish the rate of impairment. A neuropsychological evaluation may also be helpful in addressing concerns about functional capacities and in determining a patients capacity to make decisions about health care or finances, and in understanding and coping with cognitive problems. In this case, the patients cognitive dysfunction prevented her from functioning at work, and she required an initial neuropsychological evaluation to determine level of her disability. Based on the results of the findings, the patient underwent treatment, including psychotherapy. The patient required repeated neuropsychological testing to obtain a proper assessment of whether the treatment was effective or not, if she would be able to return to work, and if she remained fully disabled. Therefore, neuropsychological testing was medically necessary for the evaluation 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 neurology 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 sixty-three year-old female who was diagnosed with stage IIIC endometrial cancer is requesting authorization of a PET/CT scan.Reviewers Findings:The reviewing physician found that a PET/CT scan will be very helpful in determining future care for this patient.  The reviewing physician found that the Health Plan denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

A 46-year-old male enrollee requested authorization and coverage of weekly therapy sessions with a non-plan provider for the treatment of social phobia.  The Health Plan denied the enrollees request indicating that the requested treatment is not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer overturned the health plans denial on the basis that the requested services are  medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 54-year-old female enrollee has requested coverage for Botox injections for treatment of her myofascial pain syndrome and chronic headaches. Findings:  The physician reviewer found that Botox is proven and FDA approved for chronic migraine treatment. Chronic migraine patients often have associated myofascial pain and obtain relief of neck and shoulder pain with neurotoxin injection. While there are no well-designed trials of myofascial pain treatment with Botox, small studies support its potential benefit.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested OxyContin 30 mg and OxyContin 40 mg for the treatment of the enrollees chronic pain.  Findings:  The physician reviewer found that the patient is on high dose opiates for post-laminectomy syndrome.  The Health Plan has denied coverage for OxyContin 30 mg and OxyContin 40 mg.  However, the patient was left without a viable plan for pain control.  The Centers for Disease Control and Prevention (CDC) guidelines describe the appropriate approach for treating patients in this clinical setting.  The authors noted established patients already taking high dosages of opioids, as well as patients transferring from other clinicians, might consider the possibility of opioid dosage reduction to be anxiety-provoking, and tapering opioids can be especially challenging after years on high dosages because of physical and psychological dependence.  Per the guidelines, providers should work with the patient to taper opioids to safer dosages, and providers should collaborate with the patient on a tapering plan.  The guidelines note that patients tapering opioids after taking them for years might require very slow opioid tapers as well as pauses in the taper to allow gradual accommodation to lower opioid dosages.  Thus, the current medical evidence does not recommended abrupt detoxification.  In this patients case, the provider needs to develop a treatment plan.  Until this plan is developed to safely taper these medications, the requested OxyContin 30 mg and OxyContin 40 mg are medically indicated for the treatment of this patient.Final Result: The reviewer determined that the requested medication dosages 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 anesthesiology with sub-specialty certification in pain medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for right hip replacement. The Health Plan has denied this request indicating that the requested services are not medically necessary for treatment of the patients right hip osteoarthritis. The submitted documentation supports the medical necessity of the requested services. It is well documented that the patient has a history of chronic right hip pain, which has failed less invasive treatment in the past, including arthroscopic surgery for femoroacetabular impingement. A corticosteroid injection into the right hip resulted in a significant response with the pain level decreasing to eight out of a scale from one to ten, from ten out of a scale of one to ten. This confirmed that the patients pain source is the right hip joint and not the sacroiliac joint or the lower back. The documents indicate that the patient has pain with range of motion of the right hip along with some loss of internal rotation. The pain questionnaires completed by the patient indicate severe interference with activities of daily living. The provider recommended a total hip arthroplasty for the treatment of the patients right hip osteoarthritis. The pain source was confirmed as contralateral hip. Current medical literature indicates it is appropriate timing for a total hip arthroplasty, with respect to the severity of the patients osteoarthritis and the degree of pain. The quality of life and the degree of disability due to the subjective reports are important factors in this patients case. Therefore, although there is a lack imaging evidence of severe end-stage osteoarthritis, the degree of pain, and the quality of life of this patient are important factors, which should be addressed. As such, right hip replacement is reasonable, appropriate, and medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  The parent of an enrollee has requested partial hospitalization level of care behavioral health services for treatment of the enrollees behavioral health condition.  Findings:  The physician reviewer found that partial hospitalization level of care behavioral health services was medically necessary. The American Psychiatric Association (APA) guidelines for the treatment of eating disorders states Patients need to both gain healthy body weight and learn to maintain that weight prior to discharge; patients who reach a healthy body weight but are discharged before this learning occurs are likely to immediately decreased their caloric intake to excessively low levels that are often insufficient to sustain their healthy body weight. Based on the documentation submitted for review, the statement above describes the situation of this patient. According to the APA guidelines, PHP level of care was indicated as she had only partial motivation to recover and was preoccupied with intrusive, repetitive thoughts. She also needed structure to gain weight. Therefore, the treatment at the partial hospitalization level of care was medically necessary for treatment of the patients medical condition. 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: Overturned

A 63-year-old male enrollee requested Sovaldi 400mg in combination with peginterferon and ribavirin for 12 weeks for medical treatment of his hepatitis C.  Findings:  Two physician reviewers found that the current medical evidence supports the requested regimen in this clinical setting.  It is medically appropriate to treat the patient before complications of liver disease occur.  Current national guidelines support treatment in this patients case.  Thus, Sovaldi 400mg in combination with peginterferon and ribavirin for 12 weeks is medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

The parent of an 18-year-old male enrollee has requested  residential treatment center services for treatment of the enrollees serious emotional disturbance.  Findings:  The physician reviewer found that this patient with a history of multiple behavioral problems including: major depressive disorder, recurrent, severe, in partial remission, polysubstance dependence including hallucinogens, cannabis and opiates, conduct disorder, parent-child relational problems, tic disorder not otherwise specified (NOS), anxiety disorder NOS and personality disorder NOS including narcissistic, antisocial and schizotypal was placed in the residential treatment facility for control of his behaviors which had previously been difficult to manage. Based upon the documentation provided, the patients symptoms and behaviors represented a deterioration from his usual performance status and included self injurious or risk taking behaviors that risk serious harm and cannot be managed outside of a 24-hour structured setting. Therefore, the patient required the intensity of service of residential treatment level of care and could not have been treated in a lesser intensity environment during the disputed period.