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

Nature of Statutory Criteria/Case Summary: The patients parent has requested reimbursement and prospective authorization and coverage for intensive outpatient program (IOP) services. 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. Applying the CALOCUS guidelines, this patient meets the criteria for intensive outpatient program (IOP) services. The patient is at some risk of harm (score 2) due to impulsivity and substance use, possible past suicidal ideation without any current suicidality or homicidal thoughts. The patient has demonstrated mild functional impairment (score 2) given the reported conflict with her parents, occasional skipped classes at school, and concerns about school performance. The records document significant comorbidity (score 3) due to depressed mood, ADHD, and cannabis use. The patients recovery environment is mildly stressful (score 2) considering the recent end of a romantic relationship, conflict with her brother, and struggles in school. Her recovery environment is supportive (score 2) due to her parents active participation in the program. The patient has shown moderate response to treatment (score 3). The providers state that the patient continues to have difficulty with maintaining sobriety in the program, and struggles to follow expectations and IOP rules about school attendance. The patient has been obstructive in treatment (score 3) as she continues to exhibit problem behaviors and struggles to meet program expectations. This gives the patient a composite score of 17, which is consistent with high-intensity community based services, such as IOP. Continued treatment at the IOP level of care will provide structure, family support, and individual and group treatment to address the patients substance use and other mental health issues. Therefore, 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 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.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Gamunex-C intravenous immunoglobulin (IVIG). Standard treatment of small fiber neuropathy is dependent on the underlying etiology (Hovaguimian and Gibbons). Small fiber polyneuropathy has various underlying causes, including associations with systemic autoimmune conditions (Liu, et al.). IVIG is a first-line treatment for immune-mediated neuropathies such as Guillain-Barre syndrome, chronic inflammatory demyelinating polyneuropathy, and multifocal motor neuropathy. In a retrospective study by Liu and colleagues, 55 patients with objectively confirmed small fiber polyneuropathy attributed to autoimmunity received IVIG for more than three months. The authors concluded that their results provide Class IV evidence demonstrating that IVIG is safe and effective for rigorously selected small fiber polyneuropathy patients with apparent autoimmune causality. In this case, the patient has small fiber neuropathy with a positive trisulfated heparin disaccharide (TS-HDS) antibody titer. Based on the current peer-reviewed medical literature, patients with autoimmune small fiber neuropathy may clinically improve with IVIG (Levine). Given this support, the requested Gamunex-C IVIG 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 neurology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 26-year-old male has requested coverage for past eating disorder acute inpatient care for treatment of bulimia nervosa and major depressive disorder.  Findings:  The physician reviewer found that modern psychiatric practice aims to place patients in the least restrictive treatment setting.  In general, community intervention settings are thought to offer optimization of treatment gains.  However, placement in more restrictive settings is often clinically appropriate.  In this patients case, he demonstrated impairment in all areas of functionality due to an anxious depression and co-occurring bulimia nervosa.  He was endorsing suicidal ideation.  The patient was bradycardic and hypotensive, with laboratory abnormalities.  During the hospitalization, the patient was motivated for treatment and was started on an uncomplicated medication regimen.  By the date at issue, the patient was stable and recognizing the impact of his behaviors and distorted self-image.  By the date at issue, mobilization to a less restrictive setting was indicated.   In sum, eating disorder acute inpatient treatment provided for the initial three days was medically indicated for the treatment of this patient.  However, eating disorder acute inpatient treatment provided for an additional five days was not medically necessary in this patients case.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential treatment for treatment of the enrollees alcohol dependence/related disorder, severe. Findings:  The physician reviewer found that The residential treatment provided were not medically necessary for treatment of the patients medical condition. According to the documentation submitted for review, the patients post-acute withdrawal symptoms were not severe in nature.  The patient was not a danger to himself or others, nor was he aggressive or violent. The patient was cognitively intact and he was not gravely disabled. There were no emotional, behavioral, cognitive, or impulsive symptoms that would warrant this level of care. The patient was medically and psychiatrically stable. There were no changes in his medications since admission. There were no psychiatric progress notes to support a severity that would require ongoing residential level of care. There was no evidence of a high degree of impulsivity, agitation, depression, mania, hallucinations, or any other significant symptom that would interfere with his care. He was motivated and appeared to be working the program. The patient was cooperative and participating in his treatment plan. His living environment was safe and sober, and the discharge plan was for IOP. The patients substance use disorder was recidivistic in nature and he did require further treatment. However, this could have occurred in an ambulatory, lower level of care. As of the dates in dispute, the patient no longer required the 24-hour structured residential setting. As such, the services at issue were not medically necessary for 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 reviewer is board certified in psychiatry with sub-specialty certification in addiction 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 patient is a 64-year-old woman with early progression following carboplatin and Rituxan for adenocarcinoma of the lung. The patient has not undergone treatment with Taxotere. The patient has begun salvage treatment with Iressa. The Health Plan has denied authorization for Iressa indicating that it would be considered a second-line therapy and not medically necessary.Iressa is a standard second-line therapy for non-small-cell lung carcinoma. There is no medical evidence to indicate that Iressa is not medically justified and should be withheld from the patient. Iressa has a better risk-benefit profile and should result in better patient compliance and quality of life. Furthermore, if the patient undergoes a trial of Taxotere followed by failure, she will be in a much less favorable condition to benefit from Iressa. As such, I have determined that the requested medication is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for magnetic resonance imaging (MRI) of the left shoulder for evaluation of the enrollees shoulder pain. Findings:  The physician reviewer found that the documentation submitted for review does not support a medical indication for MRI of the left shoulder. The records do not demonstrate physical exam findings consistent with impingement or brachial plexus syndrome or suspicion for mass. In addition, the submitted medical records fail to demonstrate that the patient has tried and failed four weeks of conservative therapy. There is a lack of medical literature available that supports MRI in this clinical setting. All told, the requested MRI of the left shoulder is not medically necessary for evaluation of the patients medical condition. Final Result: The reviewer determined that the requested diagnostic procedure is not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in 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

The patient is a 25-year-old woman who has severe inflammatory acne with cysts, keloids and postinflammatory hyperpigmentation. She was previously treated by a dermatologist who prescribed topicals, oral antibiotics and interlesional steroid injections. She subsequently changed health plans and is now under the care of a family practice  physician. The patient requested a referral to a dermatologist, which her Health Plan denied on the basis that it is not medically necessary.It is medically essential that this patient be treated for her severe inflammatory acne by a dermatologist. It is not within the scope of practice of a family physician to treat severe acne with cysts and scarring. Without the specialized care of a dermatologist the patient may develop more disfiguring scars, cysts and/or postinflammatory pigment changes. Given the severity of the patients condition, referral to a dermatologist is medically indicated and should be authorized. Therefore, I have determined the requested referral is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

A 46-year-old female enrollee requested authorization and coverage of radiosurgery to the abdoment and pelvis at a non-plan facility for the treatment of colon cancer with metastases.  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 services are not medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 65-year-old male enrollee has requested bilateral laminotomy with spinal instrumentation and fusion at L3-S1 for the treatment of his stenosis with radiculopathy. Findings:  Three physician reviewers found that spinal fusion is indicated for instability or spondylolisthesis. This patients records do not support such a diagnosis and thus do not demonstrate that he is a candidate for the proposed surgery. The effectiveness of dynamic stabilization systems remains unproven; some systems are currently in the midst of a post-market surveillance study to determine the long-term safety and efficacy. With the paucity of studies on dynamic stabilization and no long-term, randomized controlled clinical trials to support this procedure, it is not likely to result in a superior outcome for this patient than standard modalities.
Appeal type: Experimental/Investigational
Decision: Overturned

A 57-year-old female enrollee requested a computed tomography (CT) angiogram of the heart for medical evaluation of her dyspnea on exertion and family history of coronary artery disease (CAD). Findings:  Three physician reviewers found that based on gender, age, symptoms and modest risk factors, this patient had a low to intermediate pre-test probability of coronary artery disease. Her treadmill testing showed discordant results with abnormal ECG findings and normal stress ECHO images. In the medical literature, Taylor and colleagues reported on the appropriate criteria for cardiac CT imaging. According to the authors, the appropriateness of sequential cardiac CT imaging in this clinical setting is 8 on a scale of 1-10. This is therefore an appropriate use of this technology based on the guidelines established and recognized by the major specialty organizations including the American Heart Association and the American College of Cardiology. Consistent with this support, the requested CT angiogram of the heart is likely to be more beneficial for evaluation of this patients medical condition than any available standard therapy.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for transcervical uterine fibroid(s) ablation with ultrasound guidance, radiofrequency.Findings: Three out of three physician reviewers found that the requested services are not likely to be more beneficial than any available standard treatment for the enrollee's medical condition.This patient presents with increased symptomatology and increased fibroid size despite treatment with medication and after previous excisional treatment. Radiofrequency ablation has been requested to treat the patients fibroids. The radiofrequency ablation (RFA) procedure was first described in American medical literature in 2002, and it was approved by the U.S. Food and Drug Administration (FDA) in 2012. According to medical literatures, 94% of women in their study reported satisfaction at 12 months. Their conclusion is that the procedure is well tolerated and provides symptom relief, short recovery time, and improved quality of life. The data seems promising and RFA may be superior to the Uterine Artery Embolization (UAE) which would be the closest alternative in this case. Five-year data for the UAE procedure shows a return of symptoms in 25 to 33% of women. According to American College of Obstetricians and Gynecologists (ACOG) Practice Bulletin Number 228, Laparoscopic radiofrequency ablation can be considered as a minimally invasive treatment option for the management of symptomatic leiomyomas in patients who desire uterine preservation and are counseled about the limited available data on reproductive outcomes. While the requested radiofrequency ablation procedure may be equivalent to the patients other treatment options, long-term data is not available to deem it superior to all other therapies for fibroids. Therefore, the requested transcervical uterine fibroid(s) ablation with ultrasound guidance, radiofrequency is not likely to be more beneficial than any available standard treatment for the patient's medical condition.Final Result: The reviewers determined that the requested services are not likely to be more beneficial than any available standard treatment for the patient's medical condition. 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. All three reviewers are experts in the treatment of the enrollees medical condition and are 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 Daklinza and Sovaldi for treatment of the enrollees hepatitis C virus. Findings: The physician reviewer found that according to joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. Per the guidelines, patients with cirrhosis are high priority for treatment. In cirrhotic treatment-naive genotype 3 patients, therapy is recommended with Sovaldi and Daklinza for 24 weeks. This is based partially on the ALLY-3 study, which showed a cure rate of only 58% with 12 weeks of therapy, and the European compassionate use study which showed a cure rate of 86% with 24 weeks of therapy (Nelson, et al; Hezode, et al). Per the guidelines, Sovaldi, peg-interferon, and ribavirin is no longer a recommended regimen. Although treatment with Daklinza and Sovaldi is indicated for this patient, 12 weeks of therapy is not the recommended treatment duration per guidelines. Given that Daklinza and Sovaldi for 24 weeks is indicated for this patient per treatment guidelines, the request for Daklinza and Sovaldi at the duration of 12 weeks is not supported as medically necessary for treatment of the patients hepatitis C infection.Final Result: The reviewer determined that the requested medications for the requested duration 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 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

A 51-year-old female enrollee has requested authorization for re-treatment for a six-month period with Lamisil for treatment of her onychomycosis.  Findings:  The physician reviewer found that treatment of the patients onychomycosis is medically necessary secondary to pain, swelling and functional impairments. Medically appropriate treatment is at least three consecutive months of Lamisil. Based on the records provided, it appears the greatest duration of treatment the patient may have received was two consecutive months. Therefore, the patient did not receive the minimum medically acceptable treatment. Furthermore, treatment for a three-month period is a guideline, not an absolute. It may be that a longer course is necessary in this case.
Appeal type: Medical Necessity
Decision: Upheld

A 43-year-old female enrollee requested authorization and coverage of a power-operated vehicle (POV) for the treatment of fibromyalgia and arthritis.  The health plan denied the enrollees request indicating that a POV 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 equipment is not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  The parent of an enrollee has requested 36 hours per week of ABA therapy, 14 hours per month of supervision and two hours per month of parent training for treatment of the enrollees autism spectrum disorder. Findings: Two physician reviewers found that the submitted documentation supports the medical necessity of the requested services.  The medical evidence has demonstrated that early and intensive ABA services provide benefits for children with autism spectrum disorder.  Based on the medical records, this patient has been progressing with 36 hours of ABA per week.  The core components of an effective program include parent training hours, and intensive direct intervention in the home, community and other settings.  In this patients case, 36 hours per week of ABA therapy, 14 hours per month of supervision and two hours per month of parent training are medically indicated for the treatment of this patient. Final Result: Two reviewers 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: One reviewer is board certified in pediatrics with sub-specialty certification in developmental-behavioral pediatrics and is actively practicing. Two reviewers are board certified in neurology with special qualification in child neurology and is actively practicing. All three 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Stelara for treatment of his medical condition.  Findings:  Three physician reviewers found that there is sufficient support for the requested medication in this clinical setting.  Recent data has demonstrated that in cases refractory to immune modulator and tumor necrosis factor (TNF) alpha inhibitors, Stelara is often effective.  In a recent observational study, 79 patients (65%) had a clinical benefit within three months of receiving Stelara.  Over a median follow-up period of 9.8 months, the cumulative probabilities that patients maintained the clinical benefit for 6 and 12 months after introduction of Stelara were 93% and 68%, respectively.  This patient has demonstrated active inflammation and has not responded to multiple therapies, including two classes of biologics.  All told, the requested medication, Stelara, is likely to be of greater benefit than other treatment options.  Final Result: Three reviewers determined that the requested medication is 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:   All three reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology and are actively practicing.  All three 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.