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

Nature of Statutory Criteria/Case Summary:  An enrollee has requested partial hospitalization program treatment services for treatment of her behavioral health condition.  Findings:  The physician reviewer found that modern psychiatric practice aims to place patients in the least restrictive treatment setting. In this particular case, the treatment team who knows this patient best recommends continued treatment at the partial hospital level of care out of concern that the patient does not command the skills needed to maintain weight and function with full autonomy in the outpatient setting. This represents a critical variable in the placement determination process. The treating team justifies their determination within the context of partial hospital level of care guidelines as developed by the American Psychiatric Association. Factors that warrant partial placement based on the assessment include patient status and environmental support, psychiatric comorbidity, preoccupation with intrusive repetitive thoughts, and the need for structure to help with weight management and dietary habits. The patient has not consolidated the treatment gains necessary to maintain a healthy weight, and is at risk for undue morbidity and admission to a higher level of care in the absence of partial hospitalization. The services at issue are safe, appropriate and consistent with good medical practice. Thus, the partial hospitalization program treatment services in dispute were and are medically necessary for treatment of the patients behavioral health condition.  Final Result: The reviewer determined that the services at issue were and are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.   Credentials/Qualifications: The reviewer is board certified in psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 49-year-old female enrollee has requested authorization and coverage for an anterior spinal decompression and fusion at L5-S1 for treatment of back and leg pain.  Findings:  The physician reviewer found that there is a lack of high quality studies examining the role of surgical fusion as a treatment for lumbar disc herniation and radiculopathy (Resnick, et al.). However, Resnick and colleagues noted the following with regard to fusion: lumbar spinal fusion is not recommended as routine treatment following primary disc excision in patients with a herniated lumbar disc causing radiculopathy; lumbar spinal fusion is recommended as a potential surgical adjunct in patients with a herniated disc in whom there is evidence of preoperative lumbar spinal deformity or instability; lumbar spinal fusion is recommended as a potential surgical adjunct in patients with significant chronic axial low back pain associated with radiculopathy due to a herniated lumbar disc; re-operative discectomy is recommended as a treatment option in patients with a recurrent lumbar disc herniation; re-operative discectomy combined with fusion is recommended as a treatment option in patients with a recurrent disc herniation associated with lumbar instability, deformity or chronic axial low-back pain.  In the case of this patient, there is a lack of evidence of lumbar spinal deformity, instability or disc re-herniation. While the patient did have a positive discogram, discography is not recommended as a procedure for diagnosing discogenic low back pain in patients with chronic non-radicular low back pain, as the diagnostic accuracy for identifying discogenic pain has not been clinically proven (Chou, et al.). Additionally, false positive responses are common in persons without significant back pain and there is no evidence that the use of provocative discography to select patients for fusion improves clinical outcomes. Therefore, the patients positive discography findings should not be used as a rationale for recommending spinal fusion. Given the paucity of studies demonstrating the safety and efficacy of surgical fusion in this setting, the requested procedure is not medically necessary for treatment of the patients low back pain. The Health Plans denial was appropriate in this case.
Appeal type: Medical Necessity
Decision: Upheld

The mother of a five-year-old male enrollee requested authorization and coverage of continued intensive physical therapy services. The Health Plan denied the request indicating that the requested therapy is not medically necessary for treatment of the enrollees cerebral palsy.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.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 59-year-old woman who had a diagnosis of low bone mass sometime prior to December 2003. She has been on Fosamax and Evista for an unknown period of time. Two DEXA scans performed in December 2004 and December 2005 revealed stable osteopenia of an undisclosed aspect of her lumbar spine. In a letter dated June 2006 the patients provider states that she is having an unspecified toxic reaction to something in her environment. He apparently obtained the second scan in preparation for stopping Evista to see if it was the cause of her toxic reaction.It is unknown whether the Evista was indeed stopped after the scan. At issue is whether the repeat DEXA scan in December 2005 was medically necessary.The patient was being treated with Fosamax and Evista for osteopenia of unspecified lumbar vertebrae. For unstated reasons, her internist believed Evista might have been causing an unspecified toxic reaction. A second DEXA scan was ordered just one year after her previous scan to reassess her bone density prior to discontinuing the Evista.It is the standard of care to order a scan every two years to assess response to therapy. The patients provider was concerned about a toxic reaction to Evista and therefore was planning to discontinue the drug. It is not likely the results of the DEXA scan would have altered this decision in light of the concerns over toxicity. The submitted records do not demonstrate any appropriate clinical indication for a repeat DEXA scan one year after the patients previous scan. Accordingly, I have determined the DEXA scan at issue was not medically necessary for evaluation of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

A 59-year-old female enrollee has requested Provigil for the treatment of her behavioral health problems. Findings:  The physician reviewer found that there are studies demonstrating the benefits of Provigil in the treatment of bipolar depression. Bipolar depression is often characterized by atypical features such as hypersomnia. There are no alternatives to Provigil, which is unique in its mechanism of action. Regarding the potential side effects, psychostimulants are more often associated with switching from depression to mania than is Provigil. The submitted clinical evidence documents that this patient has significant psychiatric impairment and made a serious suicide attempt prior to her recent regimen. Since she was doing well on her recent protocol (including Provigil), it is medically appropriate and indicated for her to continue to receive Provigil.
Appeal type: Medical Necessity
Decision: Upheld

An 18-year-old female enrollee has requested eating disorder intensive outpatient program (IOP) services for treatment of her eating disorder.  Findings:  The physician reviewer found that the requested services are not medically necessary for treatment of the patients medical condition. According to the medical records submitted for review, as of the date indicated the patient is of normal body weight with a weight of 142 pounds, a height of 66 inches resulting in a body mass index (BMI) of 23. Her ideal body weight (IBW) is noted to be 130 pounds. She has no significant medical comorbidities. She is not currently an imminent threat to self or others and has a stable home environment. The patient does not demonstrate any aggressive behaviors that require containment in an intensive outpatient program. In addition, although the patient reportedly has suicidal ideation, this can be safely managed at a less restrictive level of care. Thus, the request for eating disorder intensive outpatient treatment program services is not medically necessary for treatment of the patients behavioral health condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of a patient has requested reimbursement and prospective authorization and coverage for residential treatment center (RTC) services for up to 45 days. Findings:  The physician reviewer found that at the time of admission to the RTC, the patient continued to endorse passive ideas of suicide similar to those she had twice before acted upon. Although she was not observed to binge or purge in the hospital, she had documented weight fluctuations, indicating covert manipulation of intake and likely of elimination as well. She was not stabilized on an appropriate medication regimen. She remained dysphoric, anxious, and with sleep disturbances. Applying the Child and Adolescent Level of Care Utilization System (CALOCUS), the composite score for this patient is 20, which indicates that the patient can be safely and adequately treated in a non-secure facility with psychiatric monitoring and 24-hour services, consistent with RTC level of care. However, such services should be in close proximity to the patients home. Additional CALOCUS determinates include (4) serious risk of harm in a patient with persistent thoughts of dying and a recent history of suicidal behavior; (3) moderate functional impairment with school failure and absenteeism due to panic; (1) no co-morbidity; (3) stressful recovery environment; (4) minimal support environment with father in denial and mother in different state; (3) difficulty engaging in treatment; and (2) constructive acceptance of treatment by the patient. All told, continued residential treatment, for up to 45 days, was and is medically necessary for treatment of this patients behavioral health issues. 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

A fifty-three year-old female with a long history of migraine headache is requesting reimbursement for a dental splint, Botox therapy, and the increased quantity of Amerge.  Reviewers Findings:  The reviewing physician found that past and future Botox therapy is not medically necessary for treatment of the patients medical condition.  The physician also found that NTI splint and 18 tablets of Amerage on a one-time basis are medically necessary.  The physician concluded that the Health Plan denial should be partially overturned.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 32-year-old man with long-standing erectile dysfunction of uncertain etiology. The patient has responded to treatment with oral Viagra. The Health Plan has denied authorization and coverage for Viagra indicating that an organic causation has not been identified.This patient has erectile dysfunction of uncertain etiology, possibly vasculogenic. In the absence of identification of other more specific etiologies it is not unreasonable to assume venous leakage or neurogenic/psychogenic causation. In any event, treatment of this patients erectile dysfunction should be undertaken. The patient has already been treated with Viagra and it has proven to be an effective treatment for his dysfunction. Furthermore, regardless of the presumed source of erectile dysfunction, Viagra is considered a first-line therapy. Based upon this information, the patient should continue to receive Viagra for treatment of his erectile dysfunction. Therefore, 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: Overturned

The parent of a 17-year-old female enrollee has requested authorization and coverage for a bariatric surgery consultation. The Health Plan has denied this request indicating that the requested consultation is not medically necessary for treatment of the enrollees morbid obesity.  Findings:  The physician reviewer found that per the adolescent bariatric surgery guidelines, adolescents who are potential candidates for bariatric surgery meet the following criteria with regard to BMI and co-morbid conditions: a BMI of 35 with one of the following severe co-morbidities, type 2 diabetes mellitus, moderate or severe obstructive sleep apnea, and/or pseudotumor cerebri; or a BMI of 40 with one or more of the following obesity-related co-morbidities, hypertension, dyslipidemia, obstructive sleep apnea, venous stasis disease, panniculitis, urinary incontinence, significant impairment in activities of daily living, moderate to severe non-alcoholic fatty liver disease, gastroesophageal reflux disease (GERD), severe psychosocial distress, significantly impaired quality of life, and/or weight-related arthropathies. The submitted documentation indicates this patient has a BMI greater than 40 with a diagnosis of GERD and is therefore a potential candidate for surgery. Thus, it is medically appropriate for the patient to undergo a bariatric surgery consultation at this time.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollees parent has requested authorization and coverage for heavy metal blood testing (including mercury and aluminum). In a recent publication representing a consensus of the Council on Children with Disabilities, Section on Developmental and Behavioral Pediatrics, American Academy of Pediatrics, Hyman and colleagues noted that, shared decision making calls for collaboration with families in evaluation and choice of interventions. However, the authors found there is a lack of evidence for routine testing of hair, blood, or urine for environmental toxins or heavy metals outside of laboratory screening for lead exposure. This patient has been diagnosed with autism spectrum disorder. Consistent with the recommendations in the medical literature, lead testing is indicated, while there is a lack of support for including testing for other heavy metals. All told, the requested heavy metal blood testing (including mercury and aluminum) is not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Findings:  Two of the three physician reviewers found the requested heavy metal blood testing (including mercury and aluminum) is not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested services are 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 reviewer 1 is board certified in neurology with special qualification in child neurology and is actively practicing. Physician reviewer 2 is board certified in neurology with special qualification in child neurology and is actively practicing. Physician reviewer 3 is board certified in pediatrics with subspecialty certifications in neurodevelopmental behavioral pediatrics and genetics and is 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

A female enrollee requested Harvoni 90/400mg tablets for medical treatment of her hepatitis C.  Findings:  Two physician reviewers found that per the American Association for the Study of Liver Diseases and Infectious Diseases Society of America recommendations, patients with chronic active hepatitis C should be treated with approved antiviral therapy regardless of fibrosis score.  The goal of treatment is to reduce all-cause mortality and liver-related health adverse consequences, including end-stage liver disease and hepatocellular carcinoma.  All told, Harvoni 90/400mg tablets are medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

An 82-year-old female enrollee requested a semi-electric hospital bed for medical treatment of the enrollees bilateral hip fractures.   Findings:  The physician reviewer found that the clinical criteria for a hospital bed accepted by the Centers for Medicare and Medicaid Services (CMS) is that a hospital bed is necessary if a patients body needs to be positioned in ways not possible in an ordinary bed or if the head of the bed needs to be elevated by more than 30 degrees.  The medical records in this case do not provide evidence of either of these conditions. Moreover, this patients hip fractures occurred many years ago and it is unclear why a semi-electric hospital bed would be required at this time. For these reasons the medical records do not support the requested hospital bed as medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a power operated scooter for treatment of the enrollee, who has a history of midfoot and metatarsophalangeal osteoarthritis. Findings:  The physician reviewer found that the records do not establish that the patient would be bed or chair confined without a power mobility device.  The records indicate that the patient is independent with household ambulation, and her mobility deficits are being addressed with a cane or walker.  She does not otherwise have neurological, musculoskeletal, cardiopulmonary or other organ system impairments that would preclude her from using appropriate assistive devices or an optimally configured manual wheelchair to accomplish her community level mobility.  Physical activity and exercise, moreover, are generally appropriate and recommended for conditions such as obesity and back pain, and for general musculoskeletal health.  Final Result: The reviewer determined that the requested equipment is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewer number one is board certified in physical medicine and rehabilitation 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 patient is a 38-year-old female with a history of alcohol abuse who was referred for residential treatment. Her home life was described as very difficult and she had reportedly failed numerous outpatient attempts at sobriety. The patients admission diagnoses were alcohol dependence and major depression and her current stressors included her marriage and remodeling of her house which necessitated temporary living arrangements. The patient had been drinking a bottle of wine per night, last doing so in April 2006; there were no reported symptoms of withdrawal. During treatment, the patient participated in therapy and was treated with Klonopin, 1mg decreased to 0.5mg, and Trazodone, up to 75mg per day. The patient was described as anxious, but there are no documented symptoms of anxiety or depression. The patient was discharged from residential treatment in May 2006. Her request for reimbursement was denied by the Health Plan based upon a determination that residential treatment services were not medically necessary.The submitted record does not indicate a severity of illness, either from an alcohol or a depressive standpoint, which would have necessitated residential treatment. The patient was apparently able to stop drinking on her own nine days prior to her residential treatment admission and there is no record that outpatient treatment was attempted as a first line approach. Additionally, despite the stated failure of numerous outpatient programs, there is no information as to the sort of programs the patient had participated in or the reasons for their failure. All told, there appears to be no clinical indications for residential treatment. Therefore, I have determined the services at issue were 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: A 43-year-old female enrollee has requested authorization and coverage for reduction mammoplasty for their back pain.  Findings:  The physician reviewer found that Her symptoms include upper back and shoulder pain, as well as shoulder grooving seen on photographs. The photographs are supportive that her clinical condition and functional deficit of pain are likely directly related to her macromastia. The amount of resection planned by the provider is significant at 500 grams. The American Society of Plastic Surgeons (ASPS) state that based on the results of Level I and II Evidence, reduction mammoplasty has been proven effective at reducing macromastia related symptoms and improving postoperative quality of life. The ASPS noted that the patient should have documentation of the severity of symptoms of breast hypertrophy and the impact on health related quality of life. This patients symptoms include chronic breast pain due to the weight of breasts, shoulder grooving, and upper back and shoulder pain, which satisfies these criteria. Moreover, the patient has shoulder grooving in the photographs provided for review. Based on this, the patient has functional problems that are directly related to her significant macromastia. Breast reduction is a well-known procedure that directly addresses this functional deficit and is appropriate in this clinical setting. Accordingly, the requested reduction mammoplasty is supported as medically necessary for treatment of this patients mammary hypertrophy and ptosis. 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 plastic surgery 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.