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

Nature of Statutory Criteria/Case Summary: A 23-year-old transgender enrollee has requested authorization and coverage for weekly individual therapy sessions with a therapist who utilizes attachment based narrative therapy with a psychodynamic approach, which includes guided imagery and hypnosis. Researchers state that psychotherapy is an integral part of patients treatment. Further medical literatures note there is evidence that individuals with chronic, complex mental illness seem to improve with long-term psychodynamic psychotherapy and that a greater number of sessions is associated with better outcome.  There is support for a psychodynamic component of therapy for adult patients with major depressive disorder. The use of hypnosis is also being used here as an aspect of the patients overall therapy with benefit to date. Therefore, weekly individual therapy sessions with a therapist who utilizes attachment based narrative therapy with a psychodynamic approach, which includes guided imagery and hypnosis is medically necessary for treatment of the patients medical condition.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 psychiatry with expertise in gender dysphoria 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 38-year-old female enrollee has requested a PET scan for an evaluation of her thyroid cancer. Findings:  The physician reviewer found that a review of the literature indicates the sensitivity of PET in well-differentiated thyroid cancer (which includes papillary) was between 47% and 100%; true-positive FDG-PET findings correlated with increasing thyroglobulin levels. In one study, PET was found to be superior to thyroglobulin levels in identifying cervical lymph node metastases. In another study, the results of PET changed the clinical management in 44% of the patients. There is sufficient evidence in the literature to establish the efficacy of PET for thyroid cancer; its use in this instance is medically appropriate.
Appeal type: Medical Necessity
Decision: Upheld

A 66-year-old male enrollee has requested for tomotherapy  for treatment of his prostate cancer. Findings:  The physician reviewer found that tomotherapy is an integrated machine that offers one form of image-guided intensity modulated radiation therapy (IMRT). There are many different platforms that offer image-guided IMRT, and no one platform has been demonstrated to be superior. Image-guidance may be performed with or without fiducials, regardless of whether tomotherapy is used. Fiducial placement involves a procedure similar to a biopsy. It is a well-established form of image-guidance, as demonstrated by Hsu and colleagues. If a patient can tolerate a biopsy without difficulties, fiducial placement should not be problematic. Ultrasound-based image guidance is an alternative form of image guidance that does not require any procedures. Tomotherapy does not involve the performance of an MRI prior to treatment, but rather a megavoltage cone-beam computed tomography (CT). Megavoltage cone-beam CT has poorer soft tissue resolution as compared to kilovoltage units present on many modern linear accelerators; both can perform image guidance without fiducials, but fiducials are often preferred even with cone-beam CT.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential treatment center services. The Health Plan has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavioral health condition. Findings: The patient presented to the RTC acutely intoxicated. Under Dimension 1, the patients score is a 3, which correlates to acute intoxication and/or withdrawal potential. He has relapsed on cocaine and methamphetamine. The client experienced withdrawal symptoms of runny nose, paranoia, anxiety, depression, night sweats, and emotional instability. The symptoms were considered manageable and did not require intensive inpatient treatment. The patient has a history of seven overdoses with combining heroin and cocaine. Under Dimension 2, which correlates to biomedical conditions and complications, the patients score is a 0. The patient did not have any biomedical conditions or complications. Dimension 3 measures emotional, behavioral or cognitive conditions or complications medical/addictive/psychiatric co-morbidities. The patients score is a 3. The patient has severe emotional and behavioral symptomatology. The patient was impulsive, and the patients longest time of being sober outside a treatment setting was 2.5 months. Dimension 4, correlates with readiness to change. The patients score is a 2. The patient agreed to come into treatment. He reported that he wanted to remain sober to avoid homelessness. However, he frequently would miss therapy sessions and group sessions. He had a low readiness to change and was passively involved in treatment. Under Dimension 5, which correlates to relapse, continued use or continued problem potential, the patients score is a 3. The patient had poor coping skills and was a high relapse risk. Dimension 6, recovery/living environment is scored a 3. The patient was homeless and did not have a supportive environment. The patients mother was involved in the finances, but it appeared that the patient was not welcome to live with her. The patient met the medical necessity criteria to be treated in an RTC setting. The patient was homeless, had very little support, had a long history of relapsing without a structured setting and was impulsive. Therefore, RTC level of care was medically necessary for treatment of this patients medical condition.Final Result: The reviewer determined that that the services at issue were medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Overturned

A 48-year-old female enrollee has requested for an MRI of the left breast for evaluation of her breast calcifications.  Findings:  Three physician reviewers found that there are several indications for MRI of the breast, which include a determination of the pre-operative extent of cancer, post-operative residual cancer, the extent of lobular cancer, the identification of an occult primary cancer with positive axillary lymph nodes, the screening of high risk patients, and problem solving. An indication for non-malignant disease is the evaluation of breast implants. High risk patients are those with a personal or family history of breast cancer or a genetic predisposition for breast cancer such as a BRCA 1 or BRCA 2 gene. High risk patients also include those with biopsy-proven atypia, lobular carcinoma in situ, radial scar or prior mantle radiation.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 58-year-old male with a history of daytime somnolence resulting from non-REM narcolepsy/idiopathic hypersomnolence. The patients history includes a polysomnography that ruled out obstructive sleep apnea, periodic leg movement and/or narcolepsy. The patient indicates he is employed as an attorney and excessive sleepiness is affecting his employment and is creating a driving hazard. The patient consulted a sleep specialist who prescribed Provigil. The submitted documentation indicates the patients symptoms have improved with use of Provigil.The apparent diagnosis in this case is idiopathic hypersomnolence. The patient was quite symptomatic because of daytime sleepiness. Clinically, the patient has improved with Provigil. Idiopathic hypersomnolence is recognized as a sleep disorder. Given the patients therapeutic response, continued treatment with Provigil is medically appropriate and indicated. 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for psychophysiological therapy services provided and continued psychophysiological therapy services. Per the American Psychiatric Association (APA), the standard of care for major depressive disorder involves treatment with different classes of antidepressants. After a patient fails antidepressant trials from multiple classes, the APA recommends adding an adjunctive medication, such as aripiprazole, quetiapine, risperidone, or brexpiprazole. This patients records do not include documentation that the patient has undergone an adequate trial of these adjunct medications. Cognitive behavioral therapy (CBT) is also supported for first-line treatment, as well as the combination of pharmacotherapy and psychotherapy. This patients records do not include documentation that she has failed treatment with pharmacotherapy and psychotherapy. There is a lack of peer-reviewed medical literature demonstrating that biofeedback is superior to standard therapeutic approaches for the treatment of this patients major depressive disorder. Per the records provided for review, this patient was demonstrating improvement in depression and anxiety with her standard medication regimen, and there is a lack of information to support continued use of biofeedback is required for maintenance. All told, the psychophysiological therapy services provided and continued psychophysiological therapy services were not and are not medically necessary for treatment of this patient. Findings:  Three of the three physician reviewers found the psychophysiological therapy services provided and continued psychophysiological therapy services were not and are not medically necessary for treatment of this patient.Final Result: The 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.
Appeal type: Medical Necessity
Decision: Overturned

A 61-year-old female enrollee has requested Gilenya for treatment of her multiple sclerosis.  Findings:  The physician reviewer found that the submitted documentation demonstrates the medical necessity of the requested medication.  This patient has been diagnosed with relapsing-remitting multiple sclerosis, and she has been on disease modifying therapy with Avonex.  There has been limited efficacy, with progression despite therapy.  She is JCV seropositive.  Thus, Tysabri is relatively contraindicated.  Patient compliance is important in long-term therapeutics.  Generally, patients prefer oral treatments and are more likely to be compliant when compared to injectable therapies.  The current medical literature supports Gilenya in this clinical setting.  There is adequate evidence supporting the efficacy of Gilenya as oral therapy.  All told, Gilenya is medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for ustekinumab (Stelara) 90 mg/mL injections. Stelara is U.S. Food and Drug Administration (FDA) approved for Crohns disease. A large randomized controlled trial demonstrated safety and efficacy for induction and maintenance of remission in patients with moderate-to-severe Crohns disease that was resistant to anti-tumor necrosis factor (TNF) therapy. Another study showed a 73% response in patients with anti-TNF-resistant Crohns disease, and 80% of responders maintained remission for one year. The mechanism of Stelara is different from immunosuppressants and anti-TNF medications, which this patient has failed. A recent study demonstrated that a significant majority of patients who have failed an anti-TNF medication achieve and maintain response with Stelara. In this case, Stelara can control the patients disease and prevent further complications. For these reasons, the requested ustekinumab (Stelara) 90 mg/mL injections are medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in internal medicine with subspecialty 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for ultrasonic guidance for needle placement. Findings:  The physician reviewer found that eer-reviewed medical literature, there is limited medical literature supporting the use of ultrasound guidance when performing injection to the distal biceps femoris. However, Korbe and colleagues noted that ultrasonography has multiple advantages over traditional radiologic imaging modalities when used for interventional procedures including improved visualization of the anatomy while avoiding ionizing radiation and risks associated with contrast use. Daniels and colleagues found that, ultrasound-guided injections at the knee have superior efficacy to landmark-guided injections. The records provided for review document that this patient presented with diagnoses of distal biceps femoris tendinopathy, left knee osteoarthritis, and degenerative joint disease. She underwent a peritendinous injection under ultrasound guidance. The tendon that was injected was the left distal biceps femoris, which had hypoechoic, heterogenous swelling demonstrated on ultrasound. The medical literature supports the use of ultrasound-guided injections to the lower extremity in this clinical setting. Given these findings, the ultrasonic guidance for needle placement was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.  Findings:  Two of the three physician reviewers found the ultrasonic guidance for needle placement was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.  Final Result: The 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: Physician reviewer 1 is board certified in anesthesiology with subspecialty certification in pain management and is actively practicing. Physician reviewer 2 is board certified in anesthesiology with subspecialty certification in pain management and is actively practicing. Physician reviewer 3 is board certified in physical medicine and rehabilitation with subspecialty certification in pain management 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: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for lumbar multilevel fusion for treatment of the enrollees back pain. Findings:  The physician reviewer found that the medical literature recommend surgery for spinal stenosis in patients who do not improve with conservative treatment. Numerous studies have demonstrated the role of surgical decompression in this patient population. However, few have investigated the utility of fusion in patients without underlying instability. The inclusion of fusion is recommended for patients with demonstrated spinal instability or the likelihood of iatrogenic instability. This patient presents with a history of chronic low back pain radiating into the right lateral hip and anterolateral leg with occasional numbness and tingling in the L4-5 distribution. Signs and symptoms are consistent with neurogenic claudication. Functional difficulty is documented in activities of daily living and work activities. Clinical examination findings did not evidence a focal neurologic deficit consistent with imaging evidence of L4-5 degenerative disc disease with severe bilateral neuroforaminal narrowing and moderate right lateral recess stenosis. Evidence of long-term conservative treatment, including analgesic medication, activity modification, and physical therapy, is documented without sustained improvement. However, there is no radiographic evidence of spondylolisthesis or spinal segmental instability on flexion and extension x-rays. There is no discussion supporting the need for wide decompression that would result in temporary intraoperative instability and necessitate fusion. Overall, the requested multilevel lumbar fusion is not supported by the submitted clinical or imaging records. Final Result: The reviewer determined that the requested surgery 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 orthopedic 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.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for lumbar epidural steroid injection.Epidural steroid injections have a clinically established role in the short-term management of low back pain when the following two criteria are met: the pain is associated with symptoms of nerve root irritation and/or low back pain due to disc extrusions and/or contained herniations; and the pain is unresponsive to conservative treatment, including but not limited to pharmacotherapy, exercise or physical therapy. Kreiner and colleagues evaluated the role of epidural spine injection for the treatment of lumbar disc herniation with radiculopathy. They concluded that transforaminal epidural spine injection is recommended to provide short-term (24 weeks) pain relief in a proportion of patients with lumbar disc herniations with radiculopathy. The American Society of Interventional Pain Physicians concluded in their last published guidelines in 2013 that, for lumbar disc herniation with radiculitis, the evidence is considered good for short-term and long-term relief with local anesthetics with steroids. Evidence is superior in contained disc herniation. In a follow-up statement, they reiterated that the evidence is good for caudal epidural, interlaminar epidural, and transforaminal epidural injections with or without steroids in managing disc herniation or radiculitis. In this case, while the patient reports chronic low back pain, the submitted medical records from her neurosurgeon, neurologist and internal medicine providers do not show an assessment and diagnosis of lumbar radiculitis. The records show evaluation for chronic neck pain. Furthermore, while there is a referral from the neurosurgeon to a pain management specialist for consideration of lumbar epidural steroid injection, there is no clinical evaluation or context for this referral. Under these circumstances, the requested lumbar epidural steroid injection is not medically necessary for the patients medical condition.Final Result: The reviewer determined that the requested service is not medically necessary for the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in anesthesiology, with subspecialty certification in pain medicine, and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Otezla 30 mg for treatment of the enrollees psoriasis vulgaris. Findings: The physician reviewer found that the records provided for review document that this patient has tried and failed a three month course of methotrexate and a three month course of Humira as well as topical and intralesional steroids and topical retinoid creams. The patient has plaque psoriasis affecting the scalp, which may not provide a high body surface area of involvement, but precludes treatment with phototherapy due to inadequate penetration to the scalp. Enbrel and Humira have the same mechanism of action. Thus, when either Humira or Enbrel has been ineffective, the other medication is not likely to be an effective treatment alternative. 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 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: Upheld

A 47-year-old male enrollee requested authorization and coverage of compounded testosterone 20% cream. The Health Plan denied the request indicating that the requested medication is not medically necessary for treatment of the enrollees hypotestosteronism.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested medication is not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

The parents of a 14-year-old female enrollee have requested residential treatment services for the treatment of the enrollees behavioral health problems. Findings:  The physician reviewer found that The patient is a disturbed teenager with self-destructive potential. To recommend any form of treatment less than residential care would be dangerous and clinically inappropriate. She shows limited capacity to care for herself without around-the-clock professional supervision. In the short time she has been in residential care she has clearly been less destructive. The patient has attended almost all group and individual therapy sessions and is beginning to establish a therapeutic relationship with both therapists and staff. This would suggest she has the capacity to respond favorably to treatment and has a  restorative potential. In my experience, patients with her diagnoses can benefit from this type of intervention. Her progress is satisfactory and she is reasonably compliant given her level of pathology. Continued treatment at the residential level of care is clinically appropriate. A lesser level of care would not be safe or effective at this time.