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

A 19-year-old male enrollee has requested residential care services for treatment of his depression, not otherwise specified, generalized anxiety disorder, panic disorder, alcohol abuse and cannabis dependence.  Findings:  The physician reviewer found that there were no symptoms of withdrawal or serious medical complications requiring monitoring and containment on a 24-hour basis.  The data reviewed fails to establish the medical necessity for this level of care.  American Psychiatric Association practice guidelines indicate that patients should be treated in the least restrictive setting which is likely to prove safe and effective.  As such, residential services during this time period fail to conform to current standards of medical practice and expert consensus as indicated by the American Psychiatric Association.  All told, residential care services provided during the said timeframe  was not medically necessary in this patients case.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 58-year-old female who was treated with physical therapy following hip replacement surgery. Her symptoms included hip slippage, decreased strength and pain while climbing stairs. A physical therapy treatment program was established for the patient that included instruction in a home program. She was discharged from physical therapy after 26 sessions, 15 of which included biofeedback.  The patients request for reimbursement for the biofeedback was denied by the Health Plan citing a lack of medical necessity.The initial physical therapy evaluation and progress notes indicate a plan to improve strength, posture, closed chain proprioception and hip stability. Various therapeutic modalities were employed such as a hip stabilization exercise program, manual and active stretching, therapeutic exercise, balance and gait training, ice, and biofeedback. It appears the patient gained strength and was more comfortable with stairs by the end of her therapy. The role of biofeedback in this treatment plan however, was not clearly documented. There are no baseline parameters given with which to track the patients progress with this particular therapy. Additionally, the utility of biofeedback has not been established for the treatment of the type of symptoms experienced by the patient. Therefore, I have determined the therapy at issue was not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for laboratory testing (rupture of membranes (ROM) testing in pregnancy). Findings:  Two of the three physician reviewers found qualitative immunochromatographic testing for ruptured membranes, such as AmniSure, has been approved by the U.S. Food and Drug Administration (FDA). These tests are alternatives to traditional testing for ruptured membranes. Traditional testing includes three elements from an evaluation of vaginal fluid: ferning, nitrazine positive and pooling. This traditional testing has been noted in the literature to be accurate with low false positive rate. On the other hand, tests such as AmniSure have been shown to have a higher false positive rates. The American College of Obstetricians and Gynecologists supports the use of these tests as a second option in cases where traditional testing is equivocal or the situation is high risk. In this case, the patient did not present with risk factors that would make using traditional testing to rule out rupture of membranes unsatisfactory. Thus, ROM testing in pregnancy was not likely to have been more efficacious than other modalities for evaluating this patient. 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.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in obstetrics and gynecology 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

The parent of a six-month-old female enrollee has requested for speech therapy, occupational therapy, and physical therapy for treatment of the enrollees Down syndrome.  Findings:  The physician reviewer found that children with Down syndrome oftentimes have significant intellectual, motor, and speech delays for their chronological age secondary to this genetic diagnosis. There is ample medical literature advocating on the positive effects of speech, occupational, and physical therapy interventions for children with Down syndrome. LaForme and colleagues reported that sensorimotor occupational therapy resulted in improved motor skills when compared with an untreated control group. In addition, Ludlow and Allen reported that early intervention and a stimulation program, involving both occupational and physical therapy techniques in a variety of settings resulted in higher IQs and advanced development compared with an untreated Down syndrome population. Similarly, Angulo-Barroso and colleagues studied physical therapy utilizing treadmill intervention in infants and preschool children with Down syndrome and noted that treated children had higher levels of physical activity and walked earlier than children in an untreated control group. Further, van Bysterveldt and colleagues reported significant improvement in speech development in infants and toddlers with Down syndrome who received speech therapy integrated with letter recognition and phonological awareness.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: an enrollee has requested authorization and coverage for Viekira XR 8.33-50 mg tablet daily for 12 weeks. Findings:  The physician reviewer found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America, all patients with chronic hepatitis C, regardless of fibrosis, should be treated except those with limited life expectancy due to non-liver-related comorbid conditions.  Per the guidelines, treatment naive genotype 1b patients should be treated with Viekira XR for 12 weeks. The medication is U.S. Food and Drug Administration approved for all patients with chronic hepatitis C, genotype 1 regardless of fibrosis stage.  The guidelines also cite data showing increased survival with earlier treatment. Final Result: The reviewers determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: the physician reviewer number one 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

The parent of a six-month-old female enrollee has requested Synagis respiratory syncytial virus (RSV) vaccine for treatment of the enrollees moderate central sleep apnea with mild obstructive sleep apnea. Findings:  The physician reviewer found that the American Academy of Pediatrics (AAP) issued new guidelines for the administration of Synagis for RSV prophylaxis based on review of current peer-reviewed medical literature. Based on the guidelines, infants with neuromuscular disease or congenital anomaly that impairs the ability to clear secretions from the upper airway because of ineffective cough are known to be at risk for a prolonged hospitalization related to lower respiratory tract infection and, therefore, may be considered for prophylaxis during the first year of life. This patient, with significant hypotonia due to Prader-Willi syndrome and chromosomal deletion, as well as laryngomalacia and central apnea significant enough to require continuous supplemental oxygen therapy, is at risk for severe respiratory disease should she contract RSV infection because of inability to adequately clear secretions. Based on the AAP guidelines and standards of care, the requested Synagis is medically necessary and appropriate for this patient for the duration of the 2014-2015 RSV seasons.
Appeal type: Medical Necessity
Decision: Upheld

A 37-year-old female enrollee has requested a biopsy for treatment of her left leg injury with swelling. Findings:  The physician reviewer found the records provided for review demonstrate that this patient underwent a thorough evaluation by multiple providers. None of these evaluations reported findings that would necessitate the performance of a biopsy. Based upon the clinical documentation provided, there is no clinical indication for the requested biopsy. A biopsy is not likely to yield any useful diagnostic information in this case of this patient with a confirmed diagnosis of lymphedema. All told, the requested services are not supported as medically necessary for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Fetal Congen AB (gene panel) testing for evaluation of the enrollees pregnancy at advanced maternal age.  Findings:  Two physician reviewers found that according to the American College of Obstetricians and Gynecologists (ACOG) committee opinion for carrier screening for genetic conditions, recommendations have been made for specific conditions. The specific conditions include: screening for spinal muscular atrophy, which is recommended to be offered to all women who are considering pregnancy or are currently pregnant; Cystic fibrosis carrier screening is recommended be offered to all women who are considering pregnancy or are currently pregnant; and fragile X premutation carrier screening is recommended for women with a family history of fragile X-related disorders or intellectual disability suggestive of fragile X syndrome and who are considering pregnancy or are currently pregnant. Thus, current ACOG recommendations support testing for spinal muscular atrophy and cystic fibrosis carrier screening. However, fragile X is not recommended for all women. For the reasons provided, a portion of the fetal Congen AB (gene panel) testing performed that included screening for muscular atrophy and cystic fibrosis was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.  Final Result: The reviewers determined that a portion of the testing at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be partially overturned. Credentials/Qualifications: Reviewer 1 is board certified in obstetrics and gynecology with sub-specialty certification in maternal and fetal medicine and is actively practicing. Reviewer 2 and 3 are board certified in obstetrics and gynecology 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 sixty-three year-old female who has low back pain is requesting an MRI of the lumbar.Reviewers Findings:  The reviewing physician found that the clinical record submitted for review does not include a recent history and physical with a neurological examination or a review of the patients medications. As such, there is no clear indication for an MRI.  The reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

A 33-year-old female enrollee has requested BRCA 1 and BRCA 2 sequence gene testing (CPT code 81211) for evaluation of her risk for developing breast cancer.  Findings:  Three physician reviewers found that screening for BRCA mutations is indicated in patients whose personal or family history predicts a high likelihood of finding one of these mutations. Identifying patients who carry these mutations has clinical importance in terms of special measures aimed at risk reduction. Well-established guidelines identify those patients in whom genetic screening is warranted. According to the guidelines published by the National Comprehensive Cancer Network (NCCN), a patient without a personal family history of cancer, but who is a first-degree relative of an affected individual who is eligible for screening, is then herself eligible for screening when the relative is unavailable for testing. Since the patients mother was diagnosed at age 60, as opposed to below age 50, she is not considered eligible for testing. In the absence of an indication for BRCA genetic testing, the requested BRCA 1 and BRCA 2 testing is not likely to be more beneficial for evaluation of this patients medical condition than standard therapies.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Takhzyro 300 mg/2 mL. Researchers describe angioedema as localized and self-limiting edema of the subcutaneous and submucosal tissue, due to a temporary increase in vascular permeability caused by the release of vasoactive mediator(s). In this case, the patient has a diagnosis of hereditary angioedema, and the records document body edema along with episodes of abdominal pain. Given that the patients symptoms have been controlled on a regimen of Takhzyro, the requested medication is medically indicated. Therefore, Takhzyro 300 mg/2 mL is medically necessary for the treatment of this patient.Final Result: The reviewer determined that 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 internal medicine and in allergy and immunology 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 female enrollee has requested Dexilant 60mg for treatment of her gastroesophageal reflux disease.  Findings:  The physician reviewer found that based on review of the available records, there is no documentation that the patient has acid related symptoms. Further, based on the patients presentation, she may have non-acid reflux, which would be consistent with her history of failing numerous anti-secretory therapies. In addition, Dexilant is a long-acting version of lansoprazole, and there is no documented physiologic reason noted why the patient would be expected to respond to this medication as opposed to generic lansoprazole. For these reasons, the requested medication has not been demonstrated to be medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 51-year-old female enrollee requested authorization and coverage of a glucowatch. The Health Plan denied the request indicating that the glucowatch is not medically necessary for managing the enrollees diabetes mellitus.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested equipment is not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a seven-year-old female with cystic fibrosis who is status post jejunal atresia with resulting short gut syndrome, malabsorption and failure to thrive. Presently, she is showing good weight gain on nocturnal Pediatric Vivonex feedings via gastrostomy tube. The patients mother is requesting authorization and coverage for this nutritional product. The Health Plan denied her request based upon a determination that Pediatric Vivonex is not medically necessary.The American Academy of Pediatrics, Committee on Nutrition set forth the following national standard for nutritional intervention in its policy statement of May, 2003: All foods for special dietary use with accepted benefit for treatment of a medical condition should be reimbursed as a medical expense, provided the costs are over and above usual foods. Individual and family financial barriers to obtaining these foods should be removed. This recommendation pertains to any medical condition for which specific dietary components or the restriction of specific dietary components is necessary to treat a physical, physiological, or pathologic condition resulting in inadequate nutrition.The patient in this case is a child with chronic disease, congenital in origin, which has resulted in malabsorption and failure to thrive. The nighttime infusions of Pediatric Vivonex may not represent the entirety of her caloric intake, but it is evident that oral feedings alone do not provide sufficient calories to sustain normal growth, weight gain, and good health. In a pediatric patient such as this one with malabsorption secondary to cystic fibrosis and short gut syndrome, maintaining adequate growth and weight gain is a primary medical concern. Other nutritional products were tried previously and resulted in chronic diarrhea with no significant weight gain. The trial of Pediatric Vivonex prescribed by her pediatric gastroenterologist has resulted in an impressive increase in weight without untoward side effects. It is clear that continued nutritional support with this product is essential for the patient.Based upon the information set forth above, I have determined the requested nutritional product is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for residential treatment center (RTC) level of care. 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 4. The patient has a serious risk of harm, due to a history of prior suicide attempt, reported thoughts of suicide and self-harm, and poor insight and judgment. In terms of functional status, the records support a score of 4. The documentation noted serious functional impairment due to inability to fulfill responsibilities for her age level. The patient has been failing her classes, becoming increasingly socially isolative, and reported poor sleep, low energy, and poor appetite.With regard to comorbidity, the records support a score of 4. The patient has major comorbidity, due to the presence of depression, as evidenced by difficulty sleeping, poor appetite, and low energy. In terms of level of stress of the recovery environment, the records support a score of 4. The patient has a moderately stressful environment due to recent conflict with her parents regarding her lack of motivation and personal hygiene.With regard to level of support of the recovery environment, the records support a score of 3 due to the parents efforts to arrange counseling for the patient. In terms of resiliency and treatment history, the records support a score of 4. The patient has poor resiliency and/or response to treatment, as previous outpatient treatment did not ameliorate depressive symptoms or suicidal ideation. With regard to treatment acceptance and engagement, the records support a score of 2. The patient is able to engage in treatment. Thus, the patient has a total score of 25. In this case, the recommended level of care is medically monitored residence-based services. This is consistent with the RTC level of care. Therefore, RTC level of care 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 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: Experimental/Investigational
Decision: Upheld

A 64-year-old female enrollee requested peripheral bone density testing for medical evaluation of her osteopenia.  Findings:  Two physician reviewers found that peripheral bone density testing was not likely to be more effective for this patient than other available options. The documentation submitted for review fails to provide rationale for the peripheral bone testing performed. In addition, there is a lack documentation that demonstrates on physical exam as to why the forearm bone density testing was medically indicated. Moreover, there is no documentation that indicates if the hip or spine is hard to read or if there is hardware in these locations to provide rationale for the testing at issue. Based on the documentation submitted for review, testing at issue was not clinically indicated and not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested bortezomib injections for treatment of the enrollees medical condition.   Findings:  The physician reviewer found that the Health Plan denied coverage stating that bortezomib was approved for multiple myeloma and mantle cell lymphoma.  Primary amyloidosis due to immunoglobulin light chains and multiple myeloma are both plasma cell neoplasms.  Both diseases are the result of cancerous plasma cells that are secreting paraproteins.  In primary amyloidosis, the plasma cells involving the bone marrow are fewer in number than in multiple myeloma and the light chains have the protein characteristic of forming amyloid in tissues.  Both diseases are difficult to treat.  There is sufficient support for the requested medication in this clinical setting.  Bortezomib injections are the standard of care and are medically indicated for the treatment of this patient.  Final Result:  The reviewer determined that 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 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.