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

Nature of Statutory Criteria/Case Summary:   An enrollee has requested diazepam 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 dosage.  With regards to treating adults with insomnia, all patients should receive therapy for any medical condition, psychiatric illness, substance abuse or sleep disorder that may be precipitating or exacerbating the insomnia.  For patients who continue to have insomnia that is severe enough to require intervention, cognitive behavioral therapy is the initial therapy that is recommended.  If a patient requires a combination of behavioral therapy and medication, a short-acting medication is recommended for six to eight weeks and then tapered.  If the patient is still having symptoms, he or she may require evaluation in a sleep disorder center prior to the institution of long-term medications.  In this case, the documentation does not support that the patient has had optimization of medical and psychiatric problems or any non-pharmacologic interventions.  All told, diazepam is not medically indicated for the treatment of this patient.  Final Result: The reviewer determined that the requested medication dosage 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 internal 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Decision Dx Melanoma Gene assay performed for evalualtion of her melanoma.  Findings:  Three physician reviewers found that The National Comprehensive Cancer Network guidelines indicate that genetic testing such at the Decision Dx Melanoma Gene Assay should not be used outside of clinical trials. In addition, it is not clear that results of this assay would change treatment recommendations in this patients case. The testing at issue is not considered to be standard of care in the treatment of the patients melanoma. Therefore, the Decision Dx Melanoma Gene assay performed was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: Three reviewers determined that the testing at issue was 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: All three reviewers are board certified in dermatology 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 patients parent has requested authorization and coverage for speech therapy services. Ganz described that AAC devices provide a means of effective communication to individuals with autism spectrum disorder (ASD), many of whom are unable to use conventional speech effectively. The author describes that patients with autism stand to greatly benefit from AAC, particularly with current AAC technologies. Researchers reviewed the importance of early intervention for young patients with autism spectrum disorder, emphasizing that developmental and behavioral approaches often underlie the therapeutic strategies employed by speech and language pathologists. Although this patient has not met the goals set by his provider per the documentation provided, the patient has not plateaued in his progress. His ability to use his AAC device to communicate is improving, albeit slowly, and with less need for intensive prompting. All told, the medical literature supports the requested speech therapy services as medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in neurology with special qualification in child 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for gene test (molecular profiling). Findings:  The physician reviewer found that a pheochromocytoma is a rare neuroendocrine tumor of the medulla of the adrenal glands or extra-adrenal chromaffin tissue that failed to involute after birth, which secretes high amounts of catecholamine. This condition potentially leads to symptoms which are consistent with sympathetic nervous system hyperactivity. Although pheochromocytomas are usually sporadic, about 30% of these tumors have been identified of inherited origin. Furthermore, a pheochromocytoma may be a manifestation of certain syndromes, such as MEN2.  The medical evidence reports that it is important to screen for these syndromes in order to identify comorbid potential neoplasms and disorders, such as medullary thyroid carcinoma and hyperparathyroidism. With proper identification of these conditions, it is possible to treat preventatively or early in the course of the illness, thereby limiting potential future morbidity.  For these reasons, the gene test (molecular profiling) provided was likely to have been of greater benefit than the available standard options for the evaluation of this patients medical condition. Final Result: All three of the 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: Physician reviewers 1, 2 & 3 are board certified in internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism 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: An enrollee has requested reimbursement for intensive outpatient program (IOP) services. The submitted documentation supports that the services at issue were medically necessary. The American Psychiatric Association treatment guidelines for substance use disorders notes that for many patients with a cocaine use disorder, clinical and research experience suggests the effectiveness of intensive outpatient treatment in which a variety of treatment modalities that focus on the maintenance of abstinence are simultaneously used. The IOP level of care is classified by the American Society of Addiction Medicine (ASAM) as Level 2.1 treatment, which encompasses services that are capable of meeting the complex needs of people with addiction and co-occurring conditions.In this case, the patient had the addiction and co-occurring condition of cocaine use disorder and bipolar disorder. Near the start of the services at issue, the patient was noted to be ambivalent about long term abstinence, to have impaired insight into his triggers, and to be at high risk of relapse outside of an IOP level of care. He was noted to have cravings during the period in question and he had ongoing mood issues through the end of the services at issue. Under these circumstances, the IOP services provided to the patient were medically necessary for treatment of the 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 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 60-year-old female said to have mixed inflammatory and osteoarthritic joint problems and diagnosed by her rheumatologist with rheumatoid arthritis (RA). She has been followed by the rheumatologist since 2001 and is maintained on combinations of sulfasalazine, various non-steroidal anti-inflammatory drugs (NSAIDs), Fosamax for osteoporosis, and pain medications for low back pain. She is apparently stable at present on this regimen. Her Health Plan has denied authorization for follow-up care with her rheumatologist at six-month intervals based upon their determination that these services are not medically necessary.Most rheumatologists will see new patients with RA at intervals of one to two times per month while the diagnosis is being clarified and medications are evaluated. Once stable, a patient will typically be seen at intervals of two to four months. Regular follow-up by a rheumatologist is necessary to assess the status of a patients RA, to determine if significant joint damage is occurring despite seemingly effective treatment, to assess whether current medications remain appropriate and in optimal dosages, to determine if medication side-effects are occurring, with or without the patients awareness, and to determine whether other or newer agents might be necessary for optimal treatment. It is also the responsibility of the rheumatologist to separate the patients RA from other musculoskeletal problems in order to avoid unnecessary, inappropriate, or dangerous interventions.The recommendation that this patient see her rheumatologist at intervals of one to two years falls outside the standard of care for rheumatologic practice.  The patient should be followed by a rheumatologist at four to six-month intervals for the reasons noted above.  Therefore, I have determined the requested services are medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

A 34-year-old male enrollee requested acute inpatient psychiatric hospital services for medical treatment of his bipolar disorder.   Findings:  The physician reviewer found that according to the American Psychiatric Association (APA) guidelines, the acute inpatient psychiatric hospital services provided were medically necessary for treatment of this patients bipolar disorder and borderline personality disorder. The records indicate the patient was plagued with the most serious of affective disorders. Further, the hospitalization enabled the patient to start dialectical behavior therapy while the inpatient team prepared the patient for transition to an appropriate aftercare treatment program. The services provided were for active treatment that was appropriate and reasonably expected to improve the patients condition as well as prevent a more serious episode of illness. In sum, considering the patients records, relevant peer-reviewed literature, and current practice guidelines, the acute inpatient psychiatric hospital services were medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

A 45-year-old female enrollee has requested laparoscopic adjustable gastric band (lap band) surgery for treatment of her obesity.  Findings:  The physician reviewer found that the submitted documentation establishes the medical necessity of the requested lap band surgery in this case. This patient meets generally accepted criteria for medical necessity of bariatric surgery at this time including the National Institutes of Health (NIH) criteria for weight loss surgery. Bariatric surgery is indicated for patients with a BMI of 40, or a BMI of at least 35 with serious co-morbid conditions. Thus, the patient meets the standard definition of clinically severe obesity at this time. The patient has failed prior dietary efforts and completed a thorough multidisciplinary evaluation that did not reveal any obvious dietary, behavioral or medical barriers to surgery at this time. All told, the medical necessity of the requested procedure has been established.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested ranibizumab injections for treatment of her medical condition. Findings: Two physician reviewers found that ranibizumab injections were not and are not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Best disease is a hereditary condition that causes degeneration of the central retina. Best disease may be accompanied by choroidal neovascularization (CNV) in 20% of patients.   While there is no treatment for Best disease, there is treatment for the accompanying CNV, should it occur.  The standard of care for treatment of CNV is anti-vascular endothelial growth factor agents, such as Lucentis. However, in this case there is no documentation provided to indicate that CNV is present.  Final Result: Two reviewers determined that the services at issue were not and are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: All three physician reviewers are board certified in ophthalmology 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.
Appeal type: Medical Necessity
Decision: Overturned

The patient has requested reimbursement and prospective authorization and coverage for residential treatment center (RTC) mental health services. The American Association of Community Psychiatrists Level of Care Utilization System (LOCUS) provides a reliable framework for determining the appropriate level of care for adults needing mental health treatment. Based on LOCUS criteria, this patient met the criteria for past RTC services, as well as continuation of RTC services going forward. The patient is at moderate risk of harm. The records document suicidal ideation during her days prior to discharge. The patient did not have an active plan, but she does have a history of a suicide attempt. Thoughts of suicide have been intermittent throughout her stay. She did report that she would go home and kill herself if discharged although did not have an active plan. The patient has demonstrated moderate functional impairment. She has few relationships and her mother is her main support. She has problems completing schoolwork, she is not employed, and her difficulties with hygiene led to her being placed on a showering plan. The patient presents with significant comorbidity with a history of OCD and an eating disorder with food restrictions that have resulted in unstable vital signs. These behaviors occurred at the beginning of her stay in RTC and have a moderate likelihood of recurring. The patients recovery environment is mildly stressful. The patient has limited support within her recovery environment. She has few supports aside from her mother. The patient has required multiple hospitalizations, including one for overdose. She has demonstrated poor response to treatment. The patient has been obstructive to treatment. She has intermittently refused to come to groups and meals, especially during the days approaching her discharge. She was distrusting and hostile at times towards staff and her providers. The patients composite score is consistent with medically monitored residence based services, such as RTC. Therefore, the RTC mental health treatment and continuation of residential mental health 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 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 62-year-old male enrollee has requested coverage for right knee bicompartmental arthroplasty for treatment of his right knee osteoarthritis.  Findings:  Three physician reviewers found that the patient has a history of right knee osteoarthritis, degenerative joint disease (DJD), and medial meniscus tear status post right knee arthroscopy, meniscal surgery and chondroplasty. Review of the operative note reveals normal lateral compartment of the knee. The providers notes document the patients symptoms to include pain, loss of motion, swelling, stiffness, catching in the knee (bilateral). The patients symptoms are improved with medication, sleep, massage, rest, elevation, and are made worse with work, exercise, weather, walking, and stairs, kneeling, and squatting. The providers notes include plans for surgery including right knee bicompartmental replacement with MAKO. The Health Plan has denied this request as investigational. In the peer reviewed medical literature, Morrison and colleagues evaluated 56 patients who met the eligibility criteria for knee arthroplasty. Despite less early stiffness in the bicompartmental knee arthroplasty (BKA) cohort, a significantly higher BKA complication rate has led us to recommend total knee arthroplasty (TKA) for patients with osteoarthritis. Similar findings from Palumbo and colleagues revealed inconsistent pain relief and unacceptable functional results for bicompartmental arthritis. This study consisted of 36 knees in 32 patients with a mean follow-up of 21 months. The authors concluded that short-term survival of this prosthesis was unacceptably low (Palumbo, et al). Further, Callahan and colleagues reported on 46 studies on unicompartmental prostheses and 18 studies on bicompartmental prostheses. For unicompartmental studies, the total number of enrolled patients was 2,391, with a mean enrollment of 47 patients and a mean follow-up period of 4.6 years. Ultimately the researchers found that patient outcomes appear to be worse for bicompartmental arthroplasties than for other prosthetic designs. All told, the peer reviewed medical literature indicates that total knee arthroplasty is superior to bicompartmental arthroplasty.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Nexium for treatment of her gastroesophageal reflux disease. The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication.  As a drug class, proton pump inhibitors are indicated for healing erosive esophagitis and peptic ulcer disease, as well as to manage symptomatic gastroesophageal reflux disease and acid hypersecretory states.  Duration of action, side effects, and cost characterize proton pump inhibitor variations.  No particular proton pump inhibitor can claim overall superiority, such that as a class proton pump inhibitors are interchangeable.  In this patients case, the available records do not support that her gastroesophageal reflux disease is advanced, nor has she demonstrated intolerance to specific proton pump inhibitors.  The records do not indicate that she has maximized treatment with step therapy.  All told, the requested Nexium is 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 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:   An enrollee has requested substance abuse residential treatment services for treatment of her behavioral health condition. Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the services at issue. The patient was not at risk for imminent withdrawals. She was not a threat to herself or others. She was not manic or psychotic. She was medically and psychiatrically stable. She was motivated and engaged. Her level of cravings and medication management did not require a 24-hour setting. The risk of relapse in and of itself is not a reason to keep a patient at a higher level of care in the absence of unstable psychiatric illness or the potential for harm to self or others. The patient received education to provide a better sober environment. Thus, 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 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.