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

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement and prospective authorization and coverage for 12 additional days of intensive outpatient program (IOP) services provided for treatment of the enrollees major depressive disorder, social anxiety disorder, and attention deficit hyperactivity disorder (ADHD). Findings: The physician reviewer found that a review of the patients IOP records indicate that he did not report suicidal or homicidal ideation or psychosis. The patient has longstanding anxiety issues and was noted to make good progress in the IOP. He was cooperative, calm and engaged actively in the IOP. He was able to verbalize improvement in his relationships with family as well as his target symptoms. Outpatient treatment and least restrictive options are considered the first-line of care as referenced by The American Academy of Child and Adolescent Psychiatry (AACAP), which recommends that children and adolescents be treated in the least restrictive setting possible and to maintain and foster natural supports. Cognitive behavioral therapy as a mainstay for anxiety treatment and is effective on an outpatient basis. One study noted that the cognitive-behavioral treatment program was similarly effective in anxious children with and without comorbid disorders; both groups showed clinically significant reductions in pretreatment diagnoses and symptoms. Applying the Child and Adolescent Level of Care Utilization System (CALOCUS), this patients presentation a composite score of 14, which correlates with outpatient services given his lack of suicidal or homicidal ideation, some deterioration and expected level of functioning in relationships with peers, adults and family, lack of co-morbid medical problems or substance issues, and mild issues with family relationships, and a stable housing situation. Further, the patient has a highly supportive recovery environment with family that is actively involved in treatment and attends family therapy sessions on a regular basis. Moreover, the patient has demonstrated recent successful experience in treatment and has participated actively in therapy and as shown improvement. Final Result: The reviewer determined that the services at issue were not and are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in psychiatry with 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: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested intralesional corticosteroid injections for treatment of her medical condition.  Findings:  The physician reviewer found that review of the submitted documentation and relevant literature demonstrates the medical necessity for the requested services. According to the documentation submitted for review, the patient presents with chronic plaque psoriasis and has been treated with intralesional corticosteroid injections which has reportedly been effective. Psoriasis is a chronic inflammatory condition involving thickened scaly plaques on extensor regions of the skin. Treatment of psoriasis often involves topical or intralesional steroids, topical vitamin D or systemic immunosuppressants. In this case, the request for intralesional injections is medically necessary as this has been effective for the patient and is considered to be a first-line therapy. Therefore, intralesional corticosteroid injections are medically indicated for 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 dermatology 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 reimbursement and prospective authorization and coverage for medical ventilator, ventilator supplies, and portable oxygen concentrator provided by Apria Healthcare. The management of this patient with noninvasive nocturnal ventilation is supported as medically necessary (Rand, et al.). Patients with congenital hypoventilation syndrome are at very high risk of not breathing adequately at night, leading to hypoventilation, respiratory acidosis, and respiratory arrest. As noted by the National Organization for Rare Disorders (NORD) of patients with congenital central hypoventilation syndrome (CCHS), Adequate ventilation is essential to ensure optimal growth and development of CCHS patients. The NORD guideline noted further that, Ventilation can be managed with a mechanical ventilator via tracheostomy or masks or using phrenic pacemakers. Monitoring both oxygen saturations and CO2 using end-tidal capnography at home helps ensure adequate ventilation in all conditions (sleep, awake, during illness and growth spurts). Thus, ventilatory support at night is imperative to safely management this patient. As such, all equipment necessary to provide adequate non-invasive nocturnal ventilation including the medical ventilator, ventilator supplies, and portable oxygen concentrator are appropriate. Therefore, the medical ventilator, ventilator supplies, and portable oxygen concentrator provided by Apria Healthcare were and are medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested equipment is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in internal medicine with subspecialty certifications in pulmonary diseases and critical care 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 and prospective authorization and coverage for a wearable cardioverter defibrillator rental for treatment of the enrollees cardiomyopathy. Findings:  Three physician reviewers found that based on the records provided the patient presents with a newly recognized cardiomyopathy in the setting of rapid atrial fibrillation. In this circumstance, there is potential for recovery of left ventricular function over time with medical therapy and there was no documented indication for immediate placement of a defibrillator such as sustained or inducible ventricular tachycardia, unexplained syncope or aborted sudden cardiac arrest. Placement of a prophylactic defibrillator is not recommended until a period of time (>90 days) where continued left ventricular dysfunction (ejection fraction  35%) is documented to persist in spite of appropriate treatment. A prophylactic defibrillator (wearable or implantable) before this time has not been demonstrated to improve outcome. Studies evaluating wearable defibrillators during periods of increased risk where criteria for implantable defibrillators have not yet been met are largely comprised of registry data without adequate control groups. Moreover, more recent retrospective trials in patients with newly diagnosed non-ischemic cardiomyopathy have not demonstrated benefit with prophylactic wearable defibrillators. At this time, prophylactic wearable external defibrillator would be indicated only if accepted criteria for an implantable defibrillator were met and an implantable defibrillator could not be placed, needed to be significantly delayed (or required explantation. As such, the use of a wearable defibrillator in this circumstance is not supported in the scientific literature. Final Result: The reviewers determined that the device at issue was not and is 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: Reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in cardiovascular disease 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the (Rezum system) heated water vapor. Two out of three physician reviewers found that he services at issue were likely to have been more beneficial than any available standard treatments for the patients medical condition. A variety of surgical treatments for benign prostatic hyperplasia (BPH) are available. Transurethral resection of the prostate (TURP) is a standard treatment, however, it also can lead to significant morbidity, including prolonged catheterization, incontinence, or urethral stricture/bladder neck contracture. In an effort to reduce patient morbidity, more minimally invasive techniques are being developed. A novel technology utilizing convective radiofrequency (RF) water vapor thermal therapy (Rezum System) received U.S. Food and Drug Administration approval in 2015. The principles of the technology and effective ablation of prostate adenomas were validated in histologic and magnetic resonance imaging studies. The advantage of the Rezum System is the use of convective heat energy rather than tissue ablation.The use of the Rezum System for the treatment of refractory urinary symptoms from BPH is supported as a minimally invasive treatment option in the most recent American Urological Association (AUA) treatment guidelines, including the 2019 and 2020 updates. This recommendation is secondary to a prospective, blinded, randomized controlled trial that demonstrated improvements in urinary quality of life scores and urinary flow rates that are durable through at least three years of follow up with minimal adverse outcomes. The Rezum System has also shown to have improved outcomes compared with medical management patients from the MTOPS trial.In this case, the patient had a diagnosis of BPH with lower urinary tract symptoms. This diagnosis and symptoms were appropriate for use of this minimally invasive treatment. The patient had failed conservative treatment with medical BPH management. Use of the Rezum System has significant advantages over standard treatment options (e.g., TURP) in that it is less invasive, causes less sexual dysfunction and has less adverse surgical outcomes. Accordingly, the (Rezum system) heated water vapor (CPT-53854) services at issue were likely to have been more beneficial than any other available standard treatments for the patients medical condition.Final Result: The reviewers determined that the services at issue were likely to have been more beneficial than any other available standard treatments for the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewers 1, 2 and 3 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

A 61-year-old female has requested coverage for any or all of the services/CPT codes proposed by her dental provider for treatment of her deviating jaw shift and masticatory dysfunction.  Findings:  The physician reviewer found that review of the submitted documentation demonstrates that this patient has been diagnosed with TMJ and myofascial pain disorder. Splint therapy has been shown to be beneficial in the treatment of patients with myofascial pain disorder. The relevant scientific literature indicates that a positive response to splint therapy is reported in 70% to 90% of patients.  There are various types of splints used to treat myofascial pain. While both maxillary and mandibular splints have been recommended for this patient, a single maxillary or mandibular splint is a well-accepted method for treating such patients. As such, a single maxillary or mandibular splint is medically appropriate and necessary for treatment of this patients myofascial pain disorder. The other services identified in the treatment plan are for purposes of the patients dental treatment and are not necessary from a medical standpoint.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the continuous positive airway pressure (CPAP) replacement supplies provided for treatment of the enrollees obstructive sleep apnea.Findings: The physician reviewer found that CPAP is recommended as the first-line treatment for use in OSA. Epstein and colleagues recommend that patients with OSA should have ongoing, long-term management for their chronic disorder. The authors noted further that patients on chronic therapy should have regular, ongoing follow-up to monitor adherence to therapy, side effects, development of medical complications related to OSA, and continued resolution of symptoms. In this setting, the American Academy of Sleep Medicine (AASM) recommends at least annual follow-up visits at which time a patients use of CPAP should be evaluated including review of usage date to monitor compliance. However, it is not within the generally accepted standards of clinical practice to provide replacement CPAP supplies to patients whom a provider has not recently seen in the office or to those patients who are non-compliant with therapy. In this case, the clinical documentation provided for review was limited to the sleep study from 2011. There is no report that the patient has been seen to follow-up on his OSA as recommended by AASM practice guidelines. Given the lack of clinical records demonstrating that the patient continues to benefit from CPAP treatment, the CPAP replacement supplies provided were not medically necessary for treatment of this patients medical condition.Final Result: The reviewer determined that the equipment at issue was 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 neurology with sub-specialty certification in sleep 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:   The parent of an enrollee has requested blood allergy testing for treatment of the enrollees medical condition. Findings:  Three physician reviewers found that the testing at issue is not supported by the peer-reviewed literature. IgG testing for food allergen is not recommended as a diagnostic tool, although IgG is known to play a role in food tolerance (Hofmaier, et al.). While food-specific IgG may be identified more in patients with functional gastrointestinal disorders than in healthy controls, they do not correlate with the presence of abdominal pain (Zuo, et al). In addition, IgE testing is recognized in the evaluation of food allergy, although results must be interpreted by an allergy specialist in the setting of a detailed clinical history (Cox). Therefore, the blood allergy testing 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: One reviewer is board certified in gastroenterology with sub-specialty certification in pediatric gastroenterology and is actively practicing. Two reviewers are board certified in pediatric 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.
Appeal type: Medical Necessity
Decision: Upheld

A 30-year-old female enrollee requested authorization and coverage of an MRI of her cervical spine. The Health Plan  denied the request indicating that the MRI is not medically necessary for evaluation of the enrollees shoulder and neck pain.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested MRI is not medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld

A 67-year-old female enrollee has requested EECP therapy for treatment of the enrollees angina. Findings:  Three physician reviewers found that this patient has persistent chest symptoms after stenting of the LAD and diagonal branches. However, by both invasive and non-invasive assessment, there is no objective evidence of significant residual ischemia. Medical therapy has been recommended, and she has responded very well to Ranexa with control of chest symptoms. The other option recommended was EECP therapy. EECP therapy remains a Class IIB indication by American College of Cardiology guidelines. There remains very limited randomized data as to its effectiveness relative to standard medical therapy, with the largest data set from the MUST-EECP trial which showed a 37 second longer time to ischemic ECG changes in the EECP therapy group, but no significant difference in exercise duration. Based on this and larger registry data, EECP therapy continues to be recommended as a possible last resort where demonstrable ischemia is not amenable to invasive management or medical therapy. In this particular patient, there is little objective evidence of ischemia by three separate imaging modalities. However, if small vessel coronary artery disease is contributing to chest symptoms and cannot be quantified (though by thallium scan this should likely be apparent), optimal conventional medical therapy is primarily indicated. The patient has apparently had excellent relief of symptoms with the addition of Ranexa therapy. EECP therapy is not likely to be more beneficial than the current medical therapy and is not indicated at this point by the currently available limited data set.
Appeal type: Medical Necessity
Decision: Upheld

The patient is six-year-old male with a history of speech delays consisting of substitution and distorted r sounds. The patients therapist has recommended speech therapy services, which the patient received from January 2005 to February 2005. The Health Plan has denied coverage for the speech therapy services on the basis they were not medically necessary.Review of the submitted information does not document objective findings or specific functional goals for the therapy at issue. In addition, the patients delays are developmental in nature. There is no medical cause for the patients delays. Given the poorly defined objectives of therapy and the absence of a documented medical condition, there was no medical indication for speech therapy. Therefore, I have determined the therapy at issue was not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 53-year-old female with a BMI of 39. She has hypertension and a history of diabetes mellitus. In addition, the patient is status post two bariatric procedures. Her most recent procedure was Roux-en-Y gastric bypass in 1999. Currently she has abdominal symptoms and an incisional hernia, which could be symptomatic. Her primary care provider referred her for consultation with a bariatric surgeon. The Health Plan has denied this request.Given the patients current condition and history the patient should be evaluated by a bariatric surgeon. The patient has an incisional abdominal hernia and other abdominal symptoms that require evaluation by a bariatric surgeon. The referral to a bariatric surgeon by the patients primary care provider is medically indicated and necessary. Therefore, I have determined the Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for vedolizumab (Entyvio) infusions (standard loading and maintenance dosing).According to American Gastroenterological Association and American College of Gastroenterology clinical guidelines, Entyvio is recommended as a first-line therapy for ulcerative colitis. Entyvio is effective for ulcerative colitis, with minimal side effects. Entyvio is an integrin antagonist specific to the gastrointestinal tract. It has a different mechanism of action than immunosuppressants and anti-tumor necrosis factor (TNF) agents, such as Remicade, for ulcerative colitis. In this case, Entyvio is more appropriate than anti-TNF medications because the patient has had pancreatitis with the use of infliximab. Without treatment, the patient is at risk for complications, such as toxic megacolon and disease flare. For these reasons, vedolizumab (Entyvio) infusions (standard loading and maintenance dosing) are medically necessary for the treatment of the patients medical condition.Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in internal medicine with 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.