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

An enrollee has requested authorization and coverage for Acthar Gel 80units/ml 2x (5ml) vials every 35 days.Highly purified (H.P.) Acthar has a corticotropin effect, and with that, the same potential side effect profile as steroids with respect to osteoporosis, glaucoma, cataracts, weight gain, increased blood pressure and glucose intolerance. The literature indicates that H.P. Acthar is still in clinical trials. At the present time, there are no good, randomized, double blinded, placebo-controlled studies in support of H.P. Acthar for rheumatoid polymyositis or other forms of myositis, but rather small reports. H.P. Acthar is still being studied in clinical investigations as well as for other indications such as rheumatoid arthritis and sarcoidosis. In this case, while the submitted documentation indicates that the patient has a history of non-response to steroids or steroid intolerance, the patients records do not make clear that the patient actually received full dose methotrexate up to 25 mg weekly for at least 12 weeks. Additionally, there does not appear to have been a trial with Imuran, Cellcept, tacrolimus, Cytoxan or other disease-modifying antirheumatic drugs (DMARDs), which may be more helpful, long term, than Acthar gel. Under these circumstances, Acthar Gel 80 units/ml x2 (5ml) vials every 35 days is not medically necessary to treat the patients medical condition.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 subspecialty 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
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for (1) testing body biofeedback, (2) non-invasive vagus nerve stimulation, (3) electrical stimulation, and (4) vestibular rehabilitation. Findings:  The physician reviewer found that the patient has multiple psychiatric diagnoses, but presents predominantly with somatic symptoms and without insight into his psychiatric diagnoses. While the patient has been evaluated for treatment-resistant depression, his presentation, based on the clinical documentation, appears to be most consistent with a primary psychotic disorder. In this case, as is quite common in the early treatment of psychosis, particularly for patients predominantly with somatic delusions as in this case, the patients psychotic symptoms and agitation have not yet been adequately treated, due in large part to the patients refusal of treatment and poor insight into his need for treatment of psychotic symptoms. The records do not note support from any provider in any specialty for the treatments that the patient has requested. In this case, the records do not document that the patient has first failed standard treatments for his current symptoms and presenting diagnosis of a primary psychotic disorder, delusional disorder. Camacho-Conde and colleagues report that brain stimulation may be a powerful tool in the remedy against neurological diseases. While treatments such as brain stimulation, biofeedback, vestibular rehabilitation, and non-invasive vagus nerve stimulation may hold promise for the treatment of neurologic disorders, in this case, the patient is not diagnosed with neurologic disorders. There is a lack of evidence supporting the use of these modalities in the treatment of psychiatric diagnoses, and more studies are needed to establish which of these treatments may hold more promise and be used in regular clinical practice in the future. Given that that this patient is requesting non-evidence based treatments for his clinical presentation, the requested services are not medically indicated. Therefore, (1) testing body biofeedback, (2) non-invasive vagus nerve stimulation, (3) electrical stimulation, and (4) vestibular rehabilitation are not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is 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 female enrollee requested psychotherapy, once or twice a week for medical treatment of her behavioral health condition.  Findings:  The physician reviewer found that the Health Plans recommendation of weekly group and twice monthly individual sessions adequately meets evidence-based treatment recommendations.  Further, the Health Plan has suggested augmentation with an intensive outpatient program which would further bolster the non-pharmacologic interventions in this case. As such, the requested services are not medically necessary for treatment of the patients behavioral health condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for whole breast ultrasound. The American College of Radiology (ACR) appropriateness criteria note that for women with dense breast tissue without additional risk factors, whole breast ultrasound may be useful as an adjunct to mammography for incremental cancer detection. The ACR notes that the balance between increased cancer detection and the increased risk of a false-positive examination should be considered in the decision. While the National Comprehensive Cancer Network (NCCN) guidelines on breast cancer do not currently include screening recommendation in women with dense breasts, current medical literature supports the use of whole breast ultrasound in women with dense breasts, though there is an increased risk of false positives. Medical literatures report that the addition of automated breast ultrasonography in a generalizable cohort of women with dense breasts increased the cancer detection yield of clinically important cancers, but it also increased the number of false-positive results. Medical literatures note that supplemental screening whole-breast sonography increases the cancer detection yield by 2.391 cancers per 1000 women with dense breast tissue over that of mammography alone but also raises the number of false-positive results. In this case, the patient is a 61-year-old female with average risk who presented for breast cancer screening.  She has documented dense breasts noted on the mammogram, and her provider recommended a whole breast ultrasound. In this case, given that current medical literature and the ACR support the use of whole breast ultrasound for breast screening in women with average-risk, the requested service is medically indicated. Therefore, whole breast ultrasound is medically necessary for the evaluation of this patient.Final Result: The reviewer determined that the requested service is medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in interventional radiology and diagnostic radiology 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 reimbursement for the intensive outpatient program (IOP) psychiatric services. The records provided for review support the medical necessity of the IOP services provided for treatment of this patients behavioral health issues. Applying the American Society of Addiction Medicine (ASAM) guidelines, the patient required the direction and continuity of care provided at the IOP level of care. The patients conditions to waxed and waned, and he continued to require supervision and guidance throughout the IOP admission. In this patients case, IOP services were in accordance with generally accepted standards of medical practice and clinically appropriate for the patients illness. Therefore, the IOP psychiatric services provided were medically necessary for the treatment of this patient.Final Result: The reviewer determined that the services at issue were medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested partial hospitalization level of care services and intensive outpatient level of care services for treatment of her behavioral health condition.  Findings: The physician reviewer found that based on the clinical documentation submitted, partial hospitalization services and intensive outpatient level of care services were not medically necessary for treatment of the patients medical condition. There is a lack of objective evidence demonstrating that continuation with a lesser intensity of care would not have offered either an expectation of improvement, or prevention of deterioration. The patients level of symptomatology did not justify partial hospitalization services, nor did her symptoms suggest intensive outpatient would have been medically necessary onward. There was no documentation of suicidal ideations or homicidal ideations. The patient has a diagnosed disorder; however she did not require medication management. The patient did not have any serious psychosocial functional or interpersonal skills deficits. Moreover, she was active in therapy reporting few to no affective symptoms and was maintaining a healthy body weight. The patient had shown improvements in all domains by and there was no reasonable expectation that continued partial hospitalization services or intensive outpatient level of care services would produce any further significant improvements. Given the above, the services at issue were not medically necessary for the 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 physician 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Vyvanse 60 mg twice daily for treatment of the enrollees attention deficit-hyperactivity disorder (ADHD). Findings:  The physician reviewer found that according to the U.S. Food and Drug Administration (FDA), the maximum daily dosage approval for Vyvanse is 70 mg per day for the treatment of ADHD. The medical literature does not show that doses of Vyvanse above 70 mg are more effective and safer than lower doses of Vyvanse. There are also cardiovascular concerns with using higher than recommended doses above 70 mg. There is also concern for potential abuse with doses higher than recommended as tolerance, psychological dependence, and severe social disability. Therefore, Vyvanse 60 mg twice daily has not been established as medically necessary for treatment of the patients ADHD. 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 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the Zoll LifeVest for treatment of the enrollees medical condition.  Findings:  The physician reviewers found the patient presented with congestive heart failure and a newly recognized cardiomyopathy with ejection fraction of less than 35%. In this circumstance there is potential for recovery of left ventricular function over time with medical therapy. In addition, there was no indication for immediate placement of a defibrillator such as sustained or inducible ventricular tachycardia, syncope or aborted sudden cardiac arrest. Placement of a prophylactic defibrillator is not recommended until a period of time at least 90 days have elapsed where continued left ventricular dysfunction with an ejection fraction of 35% or less is documented to persist despite appropriate treatment. A prophylactic wearable defibrillator before this time has not been demonstrated to improve outcomes. The studies evaluating wearable cardioverter defibrillators during periods of increased risk where criteria for implantable defibrillators have not yet been met are largely comprised of registry data without adequate control groups. A prophylactic wearable external defibrillator would be indicated only if accepted criteria for an implantable defibrillator were met and an implantable defibrillator could not be placed, needed to be significantly delayed or required explanation.  Final Result: All three reviewers determined that the device at issue was 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 number one, two, and three are board certified in internal medicine with sub-specialty certification in cardiovascular disease and are actively practicing. The reviewer 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: Upheld

Nature of Statutory Criteria/Case Summary: The parent of a 10-year-old female enrollee has requested authorization and coverage for speech therapy. The requested weekly speech therapy sessions are not supported as medically necessary for the treatment of this patients speech delay as a result of her intellectual disability and microcephaly. The provider describes that her scores on standard testing have been unchanged over three evaluations at two year intervals, and that the patients rate of progress is consistent with her natural maturation. The patient has reached a plateau, thus the Health Plans recommendation for the patient to receive speech therapy for two sessions per month for the next six months, for diagnostic therapy, parent training and institution of a home program is appropriate. For these reasons, the requested speech therapy is not medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in pediatrics and neurology with special qualification in child 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for bilateral platelet rich plasma (PRP) injections (CPT 0232T). This patient has a history of chronic bilateral knee pain due to osteoarthritis. She has undergone two arthroscopies on the right knee and one arthroscopy on the left knee. She has been treated with non-steroidal anti-inflammatory drugs (NSAIDs), corticosteroid injections, and hyaluronic acid injections. The provider recommended PRP injections. Current evidence indicates that compared with viscosupplementation and prolotherapy with saline, intra-articular PRP injections may have more benefit in pain relief and functional improvement in patients with symptomatic knee osteoarthritis at one-year post-injection. The authors found that at six months post-injection, PRP and hyaluronic acid had similar effects with respect to pain relief and functional improvement. However, at 12 months post-injection, there was better pain relief with PRP as compared to hyaluronic acid. Given this support, the requested bilateral PRP injections (CPT 0232T) are 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 bilateral PRP injections (CPT 0232T) are 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 likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. 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: Upheld

A 21-year-old female enrollee has requested for residential eating disorder program for treatment of her eating disorder.  Findings:  The physician reviewer found that this patient does not appear to meet the American Psychiatric Association (APA) treatment guidelines for the residential treatment facility. It is noted that this patient does not show deterioration of psychosocial function to put her at risk of relapse without 24-hour supervision and care. She is not reportedly experiencing a disturbance in mood, affect or cognition such that she cannot be safely managed in a less restrictive environment. The records suggest that this patient was more stabilized and could have been safely and adequately care for in a less restrictive treatment environment.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 16-year-old male who has a history of substance and alcohol abuse, depression, and cutting behavior and suicide ideation. His physician has stated the patient has tried several medications as well as partial hospitalizations without sustained benefit. He was admitted to inpatient services in July 2004 due to suicidal threatening.  He had apparently been abusing over the counter medications as well as marijuana, alcohol and cocaine. in July 2004, the patient was admitted to a residential treatment program where he remained until December 2004. The Health Plan has denied reimbursement for the services at issue on the basis such services were not medically necessary for treatment of the patients medical condition.The Health Plans denial should be upheld. There is insufficient documentation to support the medical necessity of the patients admission. Based upon the information provided, the patients mental status and behavior at time of admission is not known. Furthermore, there is inadequate documentation of the goals of treatment or of the patients progress toward such goals. There is insufficient evidence that the patients admission to this facility was medically necessary or that he required the level of care provided during the period in question. Therefore, I have determined that the services at issue were not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

A 55-year-old male enrollee has requested a computed tomography (CT) scan with contrast for evaluation of his abdominal varices.  Findings:  The physician reviewer found that there are many causes of abdominal varices, with the most common cause being portal venous hypertension.  Other causes include Budd-Chiari disease and tumors of the liver, biliary tree and pancreas.  This patient was noted to have dilated varices adjacent to the portal vein on a CT scan of the abdomen.  Subsequent abdominal ultrasound showed no evidence of portal venous hypertension.  The abdominal ultrasound, however, did not evaluate the dilated varices noted on the prior CT scan. Reevaluation of the previously documented abdominal varices is medically indicated to document stability and to try and determine the exact cause of the varices.  This is important, as abdominal varices can bleed and cause significant morbidity and mortality.  There is sufficient support in the peer-reviewed literature for the use of CT scans in the evaluation of abdominal varices.  All told, the requested CT scan with contrast is medically indicated for the evaluation of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

A 48-year-old male enrollee requested authorization and coverage of participation in a phase I clinical trial using Colchicine for the treatment of stage IV liver cirrhosis. 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 participation in a phase I clinical trial using Colchicine is not likely to be more beneficial for treatment of the enrollees stage IV liver cirrhosis 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: Overturned

A 57-year-old female enrollee has requested Xifaxan for treatment of irritable bowel syndrome/bacterial overgrowth. Findings:  The physician reviewer found that Rifaximin is FDA approved for the treatment of travelers diarrhea and has been shown to be safe and effective. There is now reasonable evidence that this medication is also useful in the treatment of irritable bowel syndrome (and bacterial overgrowth). Although other antibiotics have also been found to be effective for this condition, they may have much more significant side effects.