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

Nature of Statutory Criteria/Case Summary:  An enrollee has requested reimbursement for intensive outpatient psychiatric (IOP) services for treatment of the enrollees eating disorder and gender dysphoria. Findings:  The physician reviewer found that The documentation provided supports the medical necessity of the services at issue in this patients case. The patient continued to be symptomatic. The patient was documented as having persistent depressive and anxiety symptoms.  The patient restricted snacks, complained of nausea and fullness, and was slow to complete meals.  The patient was also noted to have intermittent suicidal ideation and self-harm thoughts. The documentation indicates that as time progressed, the patients symptoms from co-occurring disorders, MDD, PTSD, and gender dysphoria, worsened and the patient was less motivated to engage in treatment.  There was also significant familial conflict, which affected the patients progress in treatment.  At the time of discharge from IOP, it was recommended that the patient engage in higher level of care at a residential treatment facility.  The American Academy of Child and Adolescent Psychiatrys (AACAP) Child and Adolescent Service Intensity Instrument (CASII) was developed to help determine the appropriate level of service intensity for behavioral health treatment for youth.  The CASII utilizes dimensions that are relevant to the youths clinical status when determining appropriate level of service intensity. These dimensions include risk of harm, functional status, co-occurrence, environmental stress, environmental support, resiliency and/or response to services, child/adolescent involvement in services, and parent involvement in services. Based on the patients clinical history and the documentation provided, this patient met CASII criteria for intensive outpatient services.  The patients medical condition, in addition to current medical literature, support the treatment at the IOP level of care. Therefore, IOP services were medically necessary for treatment of this patients medical condition. 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 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: Upheld

The parent of a five-month-old male enrollee has Synagis vaccine for treatment of the enrollees risk for respiratory syncytial virus (RSV). Findings:  The physician reviewer found that based on the guidelines published by the American Academy of Pediatrics (AAP) and the standard of care, at his level of prematurity, Synagis would only be indicated if this patient was younger than 3 months old at the start of RSV season or if he had other risk factors for severe RSV disease. Additional risk factors include chronic lung disease, hemodynamically significant heart disease, and a neuromuscular disorder. Other factors that could be considered would be severe immunodeficiency or cystic fibrosis.  He has none of these risk factors for severe disease.Although the patient is certainly small in terms of weight, he is growing well and his weight is greater than the 5th percentile when plotted using his age adjusted for prematurity. Being small for age is not a significant risk factor for severe RSV disease. Moreover, he does not present with any chronic lung disease requiring medication, hemodynamically significant congenital heart disease, or a neuromuscular disorder that interferes with his ability to maintain his airway and manage secretions. Thus, he no longer has any significant risk factors for developing severe RSV disease therefore the requested Synagis therapy is not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 12-year-old male enrollee has requested a motorized wheelchair for treatment of the enrollee, who has been diagnosed with cerebral palsy. Findings:  The physician reviewer found that in this patients case, the requested motorized wheelchair is medically indicated. This patient is non-ambulatory, and he has limited mobility in his manual wheelchair. As he gains weight and length with puberty, his increased weight and loss of mechanical advantage with increasing arm length will result in progressive loss of mobility in a mechanical wheelchair.  A motorized wheelchair will improve quality of life in this case.  Jain and colleagues studied non-ambulatory patients with spinal cord injury, and the authors reported that increased mobility with a motorized wheelchair had a dramatic improvement in quality of life.  Medical necessity is also based on cardiac physiology.  Barfield and colleagues noted that cerebral palsy patients in mechanical wheelchairs had the greatest heart rate response to physical activity compared to other patients in wheelchairs. Thus, with increasing weight and loss of arm mechanical advantage, this patient will have increasing cardiac workload in propelling himself, either at home or at school.  This may disadvantage his cardiac wellness as he ages. All told, the requested motorized wheelchair is medically indicated for this patient.
Appeal type: Experimental/Investigational
Decision: Overturned

A 31-year-old female enrollee has requested Botox injections for the treatment of her migraine. Findings:  Two physician reviewers found that this patient has a history consistent with disabling chronic migraine and has tried and failed standard episodic migraine preventative therapy. There are no FDA-approved treatments for chronic migraine. Botox has variable, though considerable data consistent with a positive benefit as a migraine preventative, especially where the frequency of attack is high (chronically). Thus, Botox should be approved in this case as a trial for her headache symptoms.  Baseline headache frequency, severity, and disability should be recorded, and if Botox is ineffective after 2 cycles, then it should not be continued.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for percutaneous tibial nerve stimulation. Findings:  Three physician reviewer found that standard therapy, anti-muscarinic/cholinergic medications and behavior modification have both failed to resolve overactive bladder symptoms in this patients case.  The medical literature supports the services at issue in this clinical setting.  This patient had failed prior medical therapy.  At this time, no other noninvasive options show the degree of response for overactive bladder symptoms refractory to medication as percutaneous tibial nerve stimulation. Final Result: Three reviewers determined that the services at issue were 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 physician reviewers are board certified in urology 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

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for intensive outpatient program (IOP) services. Per the American Society of Addiction Medicine (ASAM) criteria, this patient met the criteria for high intensity community based services. ASAM criteria focuses on six dimensions to determine the appropriate level of care, which includes: (1) intoxication and withdrawal potential; (2) biomedical conditions; (3) emotional, behavioral and cognitive conditions; (4) readiness to change; (5) relapse, continued use, or continued problem potential; and (6) recovery environment. Applying the ASAM criteria, this patient was at serious risk of continued use and relapse. The patient endorsed continued use during IOP treatment. Kratom use may result in agitation, seizures, and respiratory depression at higher doses (DArrigo). The patients mental status was sufficient to permit participation in treatment. The patient was unable to control his substance use without intensive support. He also has comorbid depression and anxiety. The patient demonstrated limited insight and awareness regarding his need for continued care. His substance use substances continued despite the structure of the IOP and was likely to escalate in a less structured environment, especially given his struggles with family dynamics. The patient was actively oppositional in addressing his substance use disorder and he took measures to avoid detection of continued use while in IOP. His perspective impaired his ability to make decisions about his care and he attributed his issues to his mothers controlling nature. The patient did not recognize relapse triggers and lacked insight into the benefits of continued care. The records documented that the patient wanted to leave the program and continued to use substances despite attempts to engage him in recovery. The patients recovery environment was too chaotic to support his treatment goals. The documentation states that the patient was at risk for acute withdrawal as evidenced by his history of delirium tremens and his use of Kratom. All told, the IOP services 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 with subspecialty 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: Experimental/Investigational
Decision: Upheld

A 48-year-old male enrollee has requested percutaneous disc decompression for treatment of his degenerative disc disease.  Findings:  Two physician reviewers found that the patient has persistent complaints of low back pain. There is no mention of radiculopathy, nerve root tension or compression signs. The MRI demonstrated evidence of a posterolateral bulge at L4-5 with desiccation and diminished disc height and an annular fissure. There was no evidence of a disc herniation. Discectomy, either percutaneous, automated, or open, is performed for radicular pain of a neuro compressive etiology which has failed to respond to conservative treatment, or if there is a progressive neurologic deficit. In this instance, it appears the chief complaint is back pain and there is no indication of radiculopathy. A percutaneous discectomy would not be appropriate for the treatment of actual back pain which has been refractory to conservative measures.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Harvoni 90-400 mg, one tablet daily for 12 weeks for the treatment of her hepatitis C. 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 should be treated except those with limited life expectancy due to non-liver-related conditions. The guidelines recommend that all patients should be treated, regardless of fibrosis stage. This patient should be considered treatment-naive, as she was previously treated with interferon rather than PEG-interferon with ribavirin.  The guidelines recommend that non-cirrhotic, treatment-naive, genotype 1 patients should be treated with Harvoni for 12 weeks. These recommendations are based on multiple randomized clinical trials, and the medication is U.S. Food and Drug Administration (FDA) approved for all patients with chronic hepatitis C, genotype 1 infection regardless of fibrosis stage.  The current guidelines cite data showing reduced survival with delayed treatment.  Final Result: The reviewer determined that the requested medication regimen 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.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for magnetic resonance imaging (MRI).Findings:  The physician reviewer found that American College of Radiology (ACR) notes that indications for breast MRI may include screening for high-risk patients with a lifetime risk of breast cancer equal to or greater than 20%, such as patients with a genetic predisposition to breast cancer as determined by either gene testing or family pedigree. The ACR appropriateness criteria for breast pain note that MRI is generally not appropriate for the evaluation of breast pain, recommending mammography with ultrasound instead. Given the lack of support in current medical literature for the use of breast MRI in the evaluation of breast pain and as the records do not indicate that this patient meets the criteria for high-risk screening, the requested service is not medically indicated. Therefore, MRI of breast with contrast is not medically necessary for the evaluation of this patient.Final Result: The reviewer determined that the requested service 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

An 18-year-old female enrollee requested labial reduction for medical treatment of her enlarged labia.  Findings:  The physician reviewer found that labial reduction surgery reshapes the labia minora to decrease the length of the labia or create symmetry.  The traditional aim of the surgery is to decrease discomfort from chaffing or irritation.  The submitted documentation supports the medical necessity of the requested services in this clinical setting.  The medical records document that the patient has symptoms and findings of significant and symptomatic labial hypertrophy, including chronic irritation.  Therefore, the proposed procedure is within the standard of care for the indication of labial hypertrophy and is medically indicated.  The condition constitutes an abnormal condition of the body caused by a developmental abnormality.  The requested surgery is proposed to improve the symptoms associated with the abnormality.  All told, the requested labial reduction is reconstructive in nature and is medically necessary for the treatment of this patient.
Appeal type: Urgent Care
Decision: Overturned

The parent of a five-year-old male enrollee has requested for an emergency room for treatment of the enrollees cough, runny nose, fever, decreased appetite and constipation. Findings:  The physician reviewer found that these signs and symptoms are suggestive of a potentially life-threatening infection, including pneumonia, bronchitis, bacteremia and/or sepsis. Although he did not appear to be in distress, his vital signs were indicative of dehydration. Tachycardia is especially concerning in the presence of anorexia and vomiting. An elevation of respiratory rate is a sign of respiratory distress (possibly due to pneumonia or other pulmonary infection).
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested a breast ultrasound for evaluation of her medical condition.  Findings:  The physician reviewer found that the request for a breast ultrasound has not been established as medically necessary for evaluation of the patients medical condition. Ultrasound to screen for breast cancer has been shown to be a valuable adjunct to mammography, especially in patients with dense breasts, which is not present in this case. A majority of the peer reviewed literature references the additive benefits, and does not support the use of ultrasound as the primary screening modality. As noted by Berg and colleagues The addition of screening ultrasound or [magnetic resonance imaging] MRI to mammography in women at increased risk of breast cancer resulted in not only a higher cancer detection yield but also an increase in false-positive findings. Chae and colleagues concur stating, Supplemental screening whole-breast sonography increases the cancer detection yield by 2.391 cancers per 1000 women with dense breast tissue over that of mammography alone. It is beneficial for increased detection of breast cancers that are predominantly small and node negative; however, it also raises the number of false-positive results. While screening ultrasound may mildly increase the number of cancers detected, there are numbers of false positives. In conclusion, while breast ultrasound is a useful adjunct to mammography, its diagnostic accuracy alone is relatively poor, and it is not recommended as a screening modality.  Final Result: The reviewer determined that the requested services are 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

A 47-year-old female enrollee requested authorization and coverage for nasal surgery for a deviated septum and chronic sinusitis.  The enrollees health plan denied the request indicating the requested surgery is not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer overturned the health plans denial on the basis that the requested surgery is medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld

A 25-year-old male has requested approval for transcranial magnetic stimulation therapy for treatment of his major depressive disorder.   Findings:  Three physician reviewers found that the patient has suffered with depression since grade school. In addition, the patient has a history of significant alcohol dependence. The patient is reported to have been treated with selective serotonin reuptake inhibitors (SSRIs), atypical antipsychotics, benzodiazepines, and stimulants. The patient reports that he stopped medications due to intolerable side effects. His provider has recommended transcranial magnetic stimulation (TMS). Based on the peer-reviewed medical literature, TMS therapy is a treatment option for patients with refractory major depressive disorder. There is no indication in this patients records that he has tried and failed treatment with  outpatient psychotherapy or any therapies related to his history of chemical dependency. Thus, although TMS is approved by the FDA for patients who have failed to achieve satisfactory improvements from one antidepressant at an adequate dosage and duration in the current episode of illness, this patients clinical notes reflect that at the time of the requested TMS treatment, he was not taking any prescribed medications for his depression or receiving any psychotherapy or treatment directed at his chemical dependency. Therefore, the patients condition is not considered treatment refractory or showing evidence of failure to achieve satisfactory improvement. Consistent with the American Psychiatric Association (APA) practice guidelines, the requested TMS therapy is not indicated for this patients medical condition or likely to produce a superior health benefit when compared with standard therapies including augmentation strategies.
Appeal type: Medical Necessity
Decision: Overturned

A 58-year-old male enrollee has requested for IVIG therapy for treatment of his medical condition. Findings:  The physician reviewer found that electromyography and nerve conduction velocity testing confirmed neuropathy with significant slowing of multiple sensory nerves. While the neuropathic syndrome is not a classic syndrome for CIDP, CIDP can present with a variety of manifestations.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for breast cancer index test performed on 4/19/16.Findings:  Two physician reviewers found that hormone receptor positive breast cancer responds to adjuvant anti-estrogen therapies such as aromatase inhibitors and tamoxifen. These drugs are usually administered for five years after mastectomy. However, patients are at risk for recurrence of about 2% per year, nearly 15 years after diagnosis and initial surgical resection. Thus, a biomarker may help providers identify those patients who are at higher risk and making them candidates for extended anti-estrogen therapy. Along these lines, BCI is a gene expression test that generates a risk for five year recurrence. The test was studied retrospectively on paraffin embedded material from patients on the TransATAC study. In this well controlled clinical study, the breast cancer index was a good prognostic marker of breast cancer recurrence and performed better than other gene expression tests.  Final Result: Two reviewers determined that the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: All three physician reviewers are board certified in internal medicine with sub-specialty certification in medical oncology and hematology 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.