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

The parent of a seven-year-old male enrollee has requested methylcobalamin 0.25mg/ml (injectable) for treatment of his autistic disorder. Findings:  The physician reviewer found that the use of vitamin B12 is not considered a standard modality for the treatment of autism. The relevant scientific literature includes a French report which notes that vitamins B12 and B6 have been studied in autistic children with debatable results in a paucity of double blind studies (Hjeiej, et al.).  The available literature demonstrates that the use of vitamin B12 to modify abnormal behavior in autistic children has had mixed results, but generally is not associated with improvement. Further data is needed to establish that vitamin B12 is effective in modifying behavior abnormalities in patients with autism. Therefore, the requested medication is not medically necessary for treatment of this patients autism.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Humira pen injection 40 mg/0.4 mL every seven days. Findings:  The physician reviewer found that Anti-tumor necrosis factor (TNF) medications such as Humira are recommended by current guidelines and the peer-reviewed medical literature for the treatment of patients with moderate-to-severe Crohns disease. The use of Humira 40 mg more frequently than every 14 days has been demonstrated to be effective to prevent complications related to Crohns disease. The American College of Gastroenterology (ACG) guidelines state that patients with continued symptoms should have their medication dose adjusted in order to attempt to optimize therapy (Lichtenstein, et al.). According to the American Gastroenterological Association (AGA) guidelines, dosage increase is recommended when Humira levels are low and anti-Humira antibody levels are undetectable. In this case, the patient has severe Crohns disease with an extensive surgical history. The patient has active disease with perianal abscess and fistula. She has been corticosteroid dependent while on Humira 40 mg every 14 days with azathioprine, in the setting of low Humira level. The continued use of Humira 40 mg every 14 days, or a discontinuation of Humira and treatment with another medication, could result in complications of disease activity. In this patients clinical setting, the requested increase in dosage consisting of Humira pen injection 40 mg/0.4 mL every seven days is appropriate and consistent with current recommendations and guidelines. For these reasons, the requested Humira pen injection 40 mg/0.4 mL every seven days is medically necessary for 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 subspecialty 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: Upheld

A 40-year-old female patient has requested authorization and coverage for endovenous laser therapy for treatment of varicose veins. The patient is status post ligation of perforators and varices in the left leg. The patient indicates her symptoms include aching pain in her legs, swelling, restless legs, and throbbing. The Health Plan has denied authorization for endovenous laser therapy on the basis that it is not medically necessary.Based upon the submitted documentation, it has not been established that any intervention is medically indicated. The patients venous pathology and efforts at conservative management appear vague and contradictory. Thus, it has not been demonstrated that standard treatment modalities are not likely to be effective.  Furthermore, the efficacy of endovenous laser therapy remains unproven in long-term trials compared to radiofrequency ablation and stripping. Therefore, I have determined that the requested procedure is not 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: An enrollee has requested reimbursement for facial feminization surgeries. The enrollee has also requested authorization and coverage for additional facial feminization surgery. Gender dysphoria refers to distress that is caused by a discrepancy between a persons gender identity and that persons sex assigned at birth. This often results in depression and anxiety. Treatment for gender dysphoria aims to minimize dysphoria and help patients attain their sought-after gender role. Studies show that the essential purpose of transition-related treatments such as facial feminization surgery is to therapeutically treat gender dysphoria, not to improve a persons appearance. Studies for sex reassignment surgeries and the treatment of gender dysphoria, and concluded that, Gender reassignment is the only treatment for gender dysphoria that has shown significant benefits in numerous research trials and meta-analyses over the past half century. Studies show that, Transwomen have diminished mental health-related quality of life compared with the general female population. However, surgical treatments (e.g. FFS [facial feminization surgery], GRS [gender reassignment surgery], or both) are associated with improved mental health-related quality of life. Studies show that facial feminization surgery does not aim to rejuvenate the face, but rather, it helps transgender women in passing as a female and integrating into everyday society. Accordingly, the submitted documentation demonstrates that the patient has had gender dysphoria that relates to male facial features and that has not been alleviated by other treatments. There is sufficient scientific literature demonstrating that facial feminization surgery is effective in relieving gender dysphoria in patients such as this patient. Therefore, the facial feminization surgeries that the patient received were medically necessary to treat the patients medical condition, and the requested additional facial feminization surgery is medically necessary to treat the patients medical condition.Final Result: The reviewer determined that both the services in issue and 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 65-year-old female enrollee has requested for an MRI of the right breast for evaluation of her breast mass. Findings:  Three physician reviewers found that there is also a smaller nodule located in this breast that has increased in size. Mammographic and sonographic analyses described findings highly suspicious for malignancy with BIRADS category 5 attached, meaning highly suspicious for malignancy and a biopsy is recommended.  No matter what an MRI would or would not show, a biopsy is indicated in this case. The findings on an MRI would do nothing to obviate the need for biopsy and surgery.
Appeal type: Experimental/Investigational
Decision: Upheld

A 44-year-old female requested authorization and coverage of Uterine Artery Embolization (UAE) for treatment of fibroids.  The Health Plan denied the enrollee's request indicating that the procedure is experimental/investigationalThree physician reviewer performed an experimental/investigational Independent Medical Review.  Each of the three physician reviewers concluded that UAE is not likely to be more beneficial for treatment of the enrollees medical condition 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

A 47-year-old female enrollee has requested BRCA testing for evaluation of her breast cancer.   Findings:  The physician reviewer found that several organizations including the National Comprehensive Cancer Network (NCCN) have published guidelines for patients who should undergo testing for BRCA mutation. The guidelines indicate that a patient who has been diagnosed with breast cancer under the age of 45 should be tested. In addition, if a patient is under 50 and has a first degree relative who was diagnosed with breast cancer under the age of 50, she should also be tested. The guidelines note that patients with triple negative breast cancer are more likely than others to be BRCA positive. The records submitted for review report this patients tumor was not triple negative. Given this patients clinical status, she does not meet the NCCN guidelines for BRCA testing. Therefore, the requested BRCA genetic testing is not medically necessary for evaluation of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

A 48-year-old male enrollee has requested Enbrel 50mg subQ.  for treatment of his recurrent uveitis/iritis and inflammatory arthritis. Findings:  Three physician reviewers found that the patient has a history of recurrent iritis, and he has joint pain and stiffness.  The documentation notes morning stiffness, which is characteristic of inflammatory arthritis, and no evidence of synovitis or of psoriasis.  Radiographs showed erosion at the first metatarsophalangeal joint.  This patient meets criteria for undifferentiated spondyloarthritis.  He had an excellent clinical response to Enbrel, and he was unable to tolerate methotrexate.  All told, the requested medication is likely to be more efficacious than other treatment options in this clinical setting.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patients parent has requested reimbursement for brief hospital stay for inpatient electroencephalography (EEG). Findings:  The physician reviewer found that records document that this patient has a history of global developmental delay, with regression. She meets criteria for autism spectrum disorder. She also has a history of staring spells, concerning for seizures. The patient underwent evaluation with inpatient video EEG telemetry to, in order to capture the EEG during sleep and the staring spells for differential diagnosis. Capturing this patients staring episodes on video EEG for differential diagnosis and to direct appropriate treatment was appropriate to determine whether treatment with medication was indicated. Arican and colleagues noted that, electrical status epilepticus during slow-wave sleep (ESES) is an epilepsy syndrome with sleep-induced epileptic discharges and acquired impairment of cognition or behavior. The authors report that, The early diagnosis of this syndrome is essential since there is a significant correlation between permanent cognitive impairment and delayed diagnosis. Bennett-Back and colleagues described the results of video EEG telemetry in 323 children with paroxysmal events of unclear etiology. The authors found that the results of the study had a role in changing the diagnosis in 53% of patients in the study. A prospective study by Romero-Gonzalez and colleagues of 69 preschool aged children with autism spectrum disorder found that 42% had abnormalities in their EEG results. All told, the brief hospital stay for inpatient EEG was medically necessary for 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 neurology with special qualification in child neurology and expertise in neurodevelopmental disabilities 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 50-year-old female enrollee requested authorization and coverage of continued intravenous immunoglobulin (IVIG) therapy for the treatment of multifocal motor neuropathy.  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 upheld the health plans denial on the basis that the requested therapy is not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested Butrans patches for treatment of her medical condition. Findings: The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication.  The current standard of care for chronic pain is treatment in a multidisciplinary practice to include physical therapy, massage therapy, behavioral therapy, and injections to help reduce pain.  The physician reported that high-dose opiates might contribute to pain sensitization via opioid-induced hyperalgesia, decreasing patient pain threshold and potentially masking resolution of a preexisting pain condition.  The current medical evidence does not support the requested medication in this clinical setting.  Therefore, the requested Butrans patches are not medically indicated for the treatment of this patient.  Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in 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

The parent of a 14-year-old female enrollee has requested continued residential treatment eating disorder services for treatment of the enrollees eating disorder and major depressive disorder.  Findings:  The physician reviewer found the patient is receiving active treatment consistent with current practice guidelines and relevant peer-reviewed literature. Although the patient is making progress while the treatment team is preparing her for a successful transition to partial hospitalization, she has not consolidated the treatment gains necessary to succeed in a less restrictive setting.  Considering these variables and clinical presentation, coupled with the expectation that the services will improve the patients condition and prevent a more serious health condition, residential treatment is safe, appropriate and consistent with accepted medical practice. Thus, the medical necessity of residential treatment eating disorder services has been established.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for weekly psychotherapy sessions. The records provided for review document that the patient presented to her provider with significant depression, increased crying spells, debilitating anxiety with regard to work, and resultant overall decreased function at home and at work. She described feelings of inadequacy and guilt over taking care of herself, which manifested after many years of suppression. The patient reported a family history of mental illness and resistance to use of medication. Despite her history, the patient agreed to a trial of Wellbutrin. The patients dosage was later increased with good benefit. By March 2020, the provider noted that the patient demonstrated significant recovery from disabling depression and the patient was considering returning to work. Dunlop reports that, pharmacotherapy and high-intensity psychotherapy (interpersonal therapy, [cognitive behavior therapy] CBT) should be provided for patients with moderate to severe depression. The author noted that the treatment plan is typically structured into three phases, with three different goals. Acute phase treatment, typically six to 12 weeks, is focused on reducing symptoms, improving functioning, and achieving remission from the major depressive episode. Following this treatment phase, the continuation phase treatment occurs after acute response (preferably remission) has been achieved, and it lasts four to nine months to prevent relapse back into the major depressive episode. Based on the available documentation, the medication management and psychotherapy provided from October 2019 through March 2020 included services in the acute and continuation phases and restored her to a previous level of functioning both occupationally and socially. Without the outpatient therapy, as described previously, she would have been at risk of the known disabilities associated with untreated depression. Given these findings, the weekly psychotherapy sessions were medically necessary for 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for a SpaceOAR Hydrogel procedure. Current medical literature supports the use of the requested service in this clinical setting to minimize the risk for high grade radiation induced urinary, bowel, and sexual morbidity. Medical literatures report in a randomized prospective clinical trial, The randomised controlled trial in image-guided intensity-modulated radiotherapy demonstrated that SpaceOAR reduces rectal radiation dose and late gastrointestinal and genitourinary toxicities, with urinary, bowel and sexual quality-of-life improvement. These advantages were verified in observational studies in various radiotherapy types.` The National Comprehensive Cancer Network (NCCN) guidelines for the management of prostate cancer endorse the incorporation of SpaceOAR in conjunction with delivery of definitive radiotherapy. Therefore, the SpaceOAR Hydrogel procedure was likely to have been more beneficial for treatment of the patients condition than any available standard therapy.Findings:  Three of the three physician reviewers found the SpaceOAR Hydrogel procedure was likely to have been more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the service at issue was likely to have been 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 radiation oncology 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

 Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for psychiatric residential treatment center (RTC) services. Findings:  The physician reviewer found that the American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists Child and Adolescent Level of Care Utilization System (CALOCUS) provides a reliable framework for determining the appropriate level of care for adolescents needing mental health treatment. Using CALOCUS, providers score patients on a scale of 1-5 using a six-pronged Dimensional Rating System. The six dimensions include: (1) risk of harm; (2) functional status; (3) medical, addictive and psychiatric comorbidity; (4) recovery environment (a. stressors and b. supports); (5) treatment and recovery history; and (6) engagement. The composite score is then used to determine the level of care needed. The patient presents a composite score of 16, which correlates with intensive outpatient program (IOP) services. Therefore, the requested psychiatric RTC services are not medically necessary for treatment of this patients behavioral health issues. 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 with subspecialty 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.