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

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement and prospective authorization and coverage for intensive outpatient (IOP) treatment.  Findings:  The physician reviewer found that  the documentation submitted does not support the medically necessity of the services at issue in this clinical setting. A review of the patients IOP records indicate that the patient was not suffering from suicidal or homicidal ideation or psychosis. The patient has long-standing anxiety issues and appeared to have recent suicidal ideation due to uncontrolled anxiety. the patient has completed successful inpatient and PHP treatment recently. The patient continues to have anxiety symptoms. The patient's target anxiety symptoms are typical of children with anxiety disorders. Due to the fact that it may take a significant amount of time for these behaviors to show significant improvement, it appears that they are more approved appropriately treated with continued outpatient therapy, in a setting that allows generalization to home and school type environments. Outpatient treatment and least restrictive options are considered first lines of care as referenced by The American Academy of Child and Adolescent Psychiatry which recommends that children and adolescents be treated in the least restrictive setting possible and to maintain and foster natural supports.  The records indicated that this patient has separation anxiety disorder. As such, it is critical that the patient is treated in the patient's home so that the  patient is not further separated from the patient's family.  Cognitive behavioral therapy is a mainstay for anxiety treatment and is effective on an outpatient basis. As noted by Brady and colleagues, The cognitive-behavioral treatment program was similarly effective in anxious children with and without comorbid disorders; both groups showed clinically significant reductions in pretreatment diagnoses and symptoms.  In summary, the patient has stabilized and this patient's current behavioral issues are secondary to the chronic nature of the patient's anxiety and can be treated on an outpatient basis. According to the submitted documentation, the patient is not displaying symptoms that would warrant the intensity of an IOP level of care. Therefore, IOP services forward were not and are not medically necessary for the treatment of this patients medical condition. Final Result: The reviewer determined that the services at issue were not and 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 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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for bilateral mammoplasty augmentation with prosthetic implants. The World Professional Association for Transgender Health (WPATH) Standards of Care (SOC) lists breast augmentation as a treatment for patients with persistent, well-documented gender dysphoria, capacity to consent, and reasonable control over significant medical or mental health conditions. The WPATH acknowledges that for some patients, an intervention like a reduction rhinoplasty can have a radical and permanent effect on their quality of life, and therefore is much more medically necessary than for somebody without gender dysphoria. The guidelines further report, these reconstructive procedures are not optional in any meaningful sense, but are understood to be medically necessary for the treatment of the diagnosed condition. The requested bilateral mammoplasty augmentation with prosthetic implants is medically necessary to help alleviate this patients well-documented gender dysphoria and related distress. Therefore, the requested bilateral mammoplasty augmentation with prosthetic implants is medically necessary for 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 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

A 49-year-old female enrollee requested authorization and coverage of adjustable gastric (Lap-Band) surgery for the treatment of morbid obesity.  The health plan denied the enrollees request indicating that the requested surgery is considered experimental.Three physician reviewers performed an experimental/investigational Independent Medical Review.  All three physician-reviewers concluded that the requested Lap-Band 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: An enrollee has requested authorization and coverage for the medication Evrysdi (risdiplam).Spinal muscular atrophy (SMA) is an autosomal, recessive, inherited, genetic disease that is characterized by degeneration of alpha motor neurons in the spinal cord. In August 2020, the FDA approved Evrysdi for the treatment of SMA in adults and children age 2 months and older. Evrysdi is a survival of motor neuron 2 (SMN2) splicing modifier designed to treat SMA caused by mutations in chromosome 5q that lead to SMN protein deficiency. A press announcement by the FDA noted that the efficacy of Evrysdi for the treatment of patients with infantile-onset and later-onset SMA was evaluated in two clinical studies. The FDA press announcement stated that patients with later-onset SMA were evaluated in a randomized, placebo-controlled study that included patients with SMA aged two to 25 years. An open-label Phase 2 trial is evaluating Evrysdis safety and tolerability in a broad range of SMA patients, ages 6 months to 60 years, all previously treated with another SMA-targeted therapy. In this case, the patient is over 60 years old and has a diagnosis of spinal muscular atrophy. Although the FDA has approved Evrysdi for the treatment of SMA in adults and children over the age of 2, it was based on studies on patients with infantile-onset SMA (average age 6.7 months) and later-onset SMA (aged 2 to 25 years). The safety of the medication Evrysdi for patients up to 60 years of age,  is still under review. Accordingly, the requested medication Evrysdi (risdiplam) is not medically necessary to treat the patients condition.Final Result: The reviewer determined that the requested medication is not medically necessary to treat the patient's condition. Therefore, the Health Plans denial should be upheld.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: Experimental/Investigational
Decision: Upheld

A 50-year-old male has requested provocative lumbar discogram, microdecompressive lumbar discectomy and interspineous process decompression (X-Stop implantation  2 levels) for treatment of back pain.  Findings:  Three physician reviewers found that discogram and microdiscectomy were not medically indicated for treatment of this condition. There was no role for use of a discogram, as discograms are generally performed as part of a work-up for fusion surgery, which was not under consideration for this patient. Additionally, there is insufficient evidence from well-designed studies supporting the safety, efficacy and long-term results of percutaneous microdiscectomy procedures. The X Stop procedure has not been shown to be more effective than a simple laminectomy, which is the gold standard for treatment of degenerative spinal stenosis. More outcomes data is needed in regard to the durability of the X-Stop procedure.
Appeal type: Medical Necessity
Decision: Upheld

A 29-year-old male enrollee requested removal of a microchip implanted in the knee for medical treatment of his left knee osteoarthritis.  Findings:  The physician reviewer found that this patients operative report does not document that any device was implanted by the surgeon who performed the  arthroscopic procedure.  In addition, there is a lack of evidence from any imaging study that such a device was present in the knee. Thus, the procedure requested by patient is not clinically indicated and not expected to provide the patient with any medical benefit.  Hence, such a procedure is not supported as medically necessary for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Findings:  The physician reviewer found that The enrollee has requested reimbursement for advanced lipoprotein testing. The records reviewed document that this patient presented with a history of coronary atherosclerosis and hyperlipidemia. The patient underwent coronary artery calcium scoring revealed a score in the 70th percentile, with evidence of moderate overall calcified plaque distributed as scattered calcification in the proximal to mid right coronary artery, in the proximal and mid left anterior descending artery, and scattered calcification of the circumflex artery. The patients treatment regimen includes rosuvastatin with Zetia and aspirin. The patient underwent advanced lipoprotein testing during an annual follow-up visit. However, the current American Heart Association (AHA) and American College of Cardiology (ACC) guidelines do not recommend use of advanced lipoprotein testing in this patients clinical setting (Grundy, et al.). Per current AHA/ACC guidelines, while some of the lipoprotein particles may be associated with increased risk for atherosclerotic cardiovascular disease, the target of lipid lowering therapy is low density lipoprotein (LDL) cholesterol. Multiple randomized trials have shown that lowering of LDL, generally with statins, lowers risk for atherosclerotic cardiovascular disease. This patient was already started on treatment with rosuvastatin prior to undergoing the advanced lipoprotein testing. All told, the advanced lipoprotein testing was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Findings: Three of the three physician reviewers found the advanced lipoprotein testing was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for continuous positive airway pressure (CPAP) supplies and water chamber for humidifier used with positive airway. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the equipment at issue. In this case, the patient had a diagnosis of obstructive sleep apnea for which she was prescribed positive airway pressure therapy. She was noted to be compliant with her use of positive airway pressure therapy. It is well-established that positive airway pressure supplies should be replenished on a periodic basis. This is in part to maximize patient therapy with the devices. In this case, the replacement supplies that were furnished to the patient were medically appropriate and standard of care.  Therefore, continuous positive airway pressure (CPAP) supplies and water chamber for humidifier used with positive airway were medically necessary for the treatment of this patient.Final Result: The reviewer determined that the equipment at issue was 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 with sub-specialty certification in sleep 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: An enrollee has requested authorization and coverage for Dexcom continuous glucose monitor. A continuous glucose monitoring system records blood sugar levels at repeated intervals throughout the day and night. The main advantage of continuous glucose monitoring is that it can help identify fluctuations and trends that would otherwise go unnoticed. The device can help maintain tight glycemic control and prevent hyperglycemia and hypoglycemia. It can capture dangerously low overnight blood sugar levels which often go undetected, reveal high blood sugar levels between meals, show early morning spikes in blood sugar and evaluate how diet and exercise affect blood sugars. It can be used as a precautionary device in order to prevent potentially dangerous consequences of uncontrolled diabetes. Continuous glucose monitoring systems have been shown to improve hemoglobin A1C levels of diabetic patients. The medical evidence supports the requested device in this clinical setting. Therefore, Dexcom continuous glucose monitor is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested device 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 internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism 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 patient has requested authorization and coverage for Antabuse (disulfiram) 250 mg. Based on the current practice guidelines from the American Psychiatric Association (APA), Antabuse is a treatment option for patients with alcohol use disorder. The records provided for review support this patient has a long history of alcohol use disorder. The patient remains at high risk for serious medical consequences with alcohol relapse. For this patient, the benefits of ongoing Antabuse treatment outweigh the risks. Moreover, treatment with Antabuse has been better tolerated over naltrexone and has been beneficial in maintaining the patient's substance use recovery. The patient is motivated to maintain sobriety with good social support. The provider has recommended continuation of Antabuse to help facilitate this patients sobriety, as it is consistent with current medical guidelines and recommendations. For these reasons, Antabuse (disulfiram) 250 mg is medically necessary for treatment of this patient.Final Result: The reviewer determined the requested medication 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 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 47-year-old male enrollee has requested minimally invasive endoscopic spinal surgery for treatment of his neck pain. Findings:  The physician reviewer found that scientific proof of the efficacy of laser disc decompression remains poor, and well-designed studies are needed, as noted by Schenk and colleagues. At this time, there is a lack of controlled studies in the literature. While some studies have been encouraging, the published data are not sufficient to conclude that efficacy has been established. Despite the numerous procedures performed, there continues to be a paucity of published randomized clinical trials. All told, the requested minimally invasive endoscopic spinal surgery is not medically indicated for this patient.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for continued speech therapy, preferably for a period of at least six months. The benefits of speech therapy for children with autism spectrum are well established. However, published studies have not demonstrated positive outcomes of continued speech therapy in adults with autism spectrum disorder (Mulhern, et al.). Wilson and colleagues reported on a meta-analysis of published studies evaluating speech therapy in adults with autism spectrum disorder. The authors included 22 studies, which showed a wide range of effects from near-zero to large effects. Differences in intervention strategies and durations, as well as in patient characteristics and outcome measures, presented barriers to aggregation. The authors concluded that there is a need for increased high-quality research examining interventions targeting expressive communication in adults with autism spectrum disorder. The records provided for review do not document that this patient has made substantial progress over the past two years in speech therapy. A review of his most recent evaluation from 8/3/20 indicates that he met 0/3 individual speech therapy goals and 0/3 group speech therapy goals. Given the current medical literature and this patients lack of progress, continued speech therapy, for a period of at least six months, is not medically necessary for 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 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: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for acupuncture for treatment of her neck pain.Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested medication.  This patient reports neck pain of six years duration.  Her prior treatment has included physical therapy, massage, and chiropractic care.  The study by Konig and colleagues showed that acupuncture is superior to conventional massage, dry needling of local myofascial trigger points, and sham laser acupuncture, for improving active range of motion and pain in patients with chronic neck pain, especially in patients with myofascial pain syndrome. As this patient remains symptomatic despite previous care, an acupuncture trial for pain management and function improvement is supported by the peer-reviewed literature. All told, the requested acupuncture is 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 oriental 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 patient has requested reimbursement and prospective authorization and coverage for intensive outpatient program (IOP) services. The American Association of Community Psychiatrists Level of Care Utilization System (LOCUS) provides a reliable framework for determining the appropriate level of care for adults needing mental health treatment. The composite score is then used to determine the level of care needed. Applying the LOCUS framework, this patient meets the criteria for IOP services. The patient has been at some risk of harm (score 2) given her fluctuating passive and active suicidal ideation. Just within the past few days, the patient denied suicidal ideation or urges to self-harm. The patient has demonstrated moderate functional impairment (score 3) due to her inability to attend school or continue working due to her symptoms. The patient has minor comorbidities (score 2) with headaches and shoulder pain due to shoulder surgery. The patients recovery environment has been mildly stressful (score 2) as she lives with her parents, but is socially isolated from work and school. The patients recovery environment is supportive (score 2) as she lives with her parents who are supportive of her treatment goals. The patient has exhibited moderate response to treatment (score 3) as she has failed outpatient care and with several different providers. She is still at high risk of decompensation at a lower level of care. The patient has been constructive in treatment (score 2) as her providers report that she has been adherent with therapy and motivated for change. This gives the patient a composite score of 16, which is consistent with low intensity community based services. However, per LOCUS, the patients score of 3 on functional status meets the criteria for IOP level of care services. Although she has demonstrated improvement, she is still at significant risk of decompensation and harm should she not receive IOP services. The patient needs to work on applying her recently acquired DBT skills to the real world environment. Given these findings, the IOP 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 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.