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

The patients parent has requested authorization and coverage for additional 28 hours/week of direct applied behavioral analysis services (for a total of 40 hours/week) for school holiday. This patients records support a diagnosis of autism and an indication for ABA services. However, the current authorization request includes 11 goals and low levels of problem behavior. Based on so few goals, minimal challenging behaviors, and the provider requesting 12 hours per week, the additional hours are not necessary for the patient to make appropriate progress. Additionally, the requested hours during holidays and when school is out of session appears to be out of convenience for the patient. The records do not document specific rationale to support the requested additional hours of ABA services in this clinical setting. All told, the additional 28 hours/week of direct applied behavioral analysis services (for a total of 40 hours/week) for school holiday are not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is a licensed B.C.B.A, board certified in psychology, 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

A 32-year-old female enrollee requested Prometheus Anser IFX diagnostic testing for medical treatment of her Crohns disease.   Findings:  Two physician reviewers found that the records indicate a baseline of quiescent Crohns disease, so that consideration was given to stopping Remicade. The Anser IFX resulted in a positive net health outcome, supporting the indication for the assay in this case. Without the guidance that Anser IFX provided, the alternative approach of empirically stopping the drug and assessing her response off Remicade carried significant risk of precipitating a disease flare. As such, the services at issue were likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned

This patient is a 56-year-old man who has moderate to severe psoriasis over at least 20% of his body surface area. He has severe hand and foot involvement, resulting in significant pain and diminishment of function. Treatment over the past seven years has included topical medications, methotrexate, Cyclosporine, systemic and intralesional corticosteroids, Soriatane, Enbrel and Raptiva. Use of each of these medications was ineffective and/or resulted in prohibitive side effects. Although there was improvement with Cyclosporine pills, there was also significant elevation of the serum creatinine.The patients dermatologist has requested approval for Humira, which the Health Plan has denied.Humira is the only medically necessary and medically appropriate treatment for this patients debilitating psoriasis. The safety profile has been established in the studies accepted by the FDA in the approval of Humira for psoriatic arthritis. There are multiple studies supporting the drying effectiveness in treating psoriasis. Significant improvement was noted in psoriasis lesions of psoriatic arthritic patients.Humira is currently in the midst of the process for approval by the FDA for use in the treatment of plaque psoriasis. In the meantime, the off-label use of the drug is medically essential for treatment of the patients psoriasis. Therefore, I have determined 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 patient is a 26-year-old female with a body mass index (BMI) of 64. She also has comorbid conditions including shortness of breath, back pain, and gastroesophageal reflux disease. The patient has had a psychiatric evaluation. The examining psychiatrist indicated the patient is not an appropriate candidate for weight loss surgery due to a history of major depressive disorder and an eating disorder. The psychiatrist believes the patient is at risk of non-compliance with pre- and post-operative requirements. With a BMI of 64 and comorbid conditions, the patient meets nationally accepted medical necessity criteria for consideration of weight loss surgery. It is highly likely that gastric bypass surgery will be beneficial for this patient. Furthermore, the patient does not require further dietary workup prior to undergoing weight loss surgery. There is no scientific evidence demonstrating that structured diet or exercise plans have been successful in the treatment of the obese. In fact, the Swedish obesity study identifies that even though there may be reduction or resolution of some symptoms with diet and exercise, surgery has the longest and best long-term outcome for the obese. However, although medically the patient meets criteria for consideration of weight loss surgery, the patient has not obtained psychiatric clearance for weight loss surgery. Psychiatric clearance must be obtained prior to surgical intervention. Based upon the information set forth above, I have determined that the requested surgery is medically necessary for treatment of the patients medical condition depending upon psychiatric clearance. Therefore, the Health Plans denial should be overturned. If the patient obtains psychiatric clearance for weight loss surgery, gastric bypass surgery should be authorized. If the patient does not obtain psychiatric clearance for weight loss surgery, gastric bypass surgery should not be authorized.
Appeal type: Medical Necessity
Decision: Upheld

A 38-year-old female enrollee requested authorization and coverage of dilatation and curettage for the treatment of endometrial hyperplasia.  The Health Plan denied the enrollees request indicating that the requested treatment is not medically necessary.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 for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 55-year-old male enrollee has requested a prophylactic knee brace for the treatment of his knee status-post surgery. Findings:  The physician reviewer found that the peer-reviewed literature generally produces statistically valid conclusions or consensus within the medical community when evaluating fairly common and clearly defined injuries. This patients presentation was different than most post ACL reconstruction patients. It was noted, that this patient had multiple diagnoses including ACL reconstruction, medial meniscectomy, lateral meniscus repair, microfracture of the medial femoral condyle, and chondroplasty of the femoral trochlea and patella. This is an unusual situation and thus peer-reviewed literature concerning this specific clinical scenario is lacking. However, given the multiple serious orthopedic diagnoses involved in this case, as well as the patients high risk occupation, it was medically reasonable and appropriate to utilize a prophylactic knee brace to attempt to prevent re-injury to his knee. The specific factors involved in this case placed the patient at high risk for re-injury and thus a prophylactic knee brace was clinically indicated.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: A 34-year-old female enrollee has requested authorization and coverage for transcranial magnetic stimulation (TMS). Findings:  The physician reviewer found that the records provided for review document that this patient has been diagnosed with schizoaffective disorder, bipolar type, personality disorder, OCD, disorder social anxiety disorder, generalized anxiety disorder, panic disorder, anorexia, and psychotic symptoms. She has been tried on several antidepressants and mood stabilizers in the past. However, the records do not indicate whether the medication trials were adequate, taking into account the maximum tolerated dosage and duration of treatment with each medication trial. Overall, there is a lack of evidence regarding the failure of available standard therapy for treatment of this patients symptoms to support treatment with TMS. Thus, the requested TMS is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: Two of the three reviewers determined that the requested services 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:  One reviewer is board certified in psychiatry and is actively practicing. One Reviewer is board certified in psychiatry and is actively practicing.  One Reviewer is board certified in psychiatry and is 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: Experimental/Investigational
Decision: Upheld

A 47-year-old female enrollee requested BRCA1 and BRCA2 genetic testing for medical evaluation of her family history of breast cancer.  Findings:  Three physician reviewers found that screening for BRCA mutations is indicated in patients whose personal or family history predicts a high likelihood of finding one of these mutations. Identifying patients who carry these mutations has clinical importance since it mandates the adoption of special measures aimed at risk reduction. Well-established guidelines identify those patients in whom genetic screening is warranted. As per the guidelines, testing is not warranted in the patient. Since the patient does not meet the standard criteria, the requested BRCA1 and BRCA2 genetic testing is not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld

A 57-year-old male enrollee has requested an MRI of the left shoulder for evaluation of the enrollees shoulder pain. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested diagnostic procedure in this patients case.  Per the clinical records, this patients condition is suspicious for partial rotator cuff tear and possible biceps tendon tear.  Current guideline recommended a trial of conservative therapy, including physical therapy and exercises under supervision, as well as home exercises in cases of chronic shoulder pain.  In this patients case, there is no documentation of recent conservative therapy, including physical therapy.  The current medical evidence does not support the requested diagnostic procedure in this setting.  All told, the requested MRI of the left shoulder is not medically indicated for the evaluation of this patient.
Appeal type: Medical Necessity
Decision: Upheld

This case concerns a 10 year and 6 month old male who is taking Concerta and Ritalin for attention deficit disorder.  He was referred for an endocrinology consultation because of slowing growth. The patient had an MRI of the brain in November 2004, which was normal and unchanged from a previous study in 2002. Growth hormone (GH) provocative testing showed a normal peak level response of 11.5 ng/ml to L-dopa, but an apparently inadequate response to clonidine of 1.6 ng/ml at 60 minutes. The patients IGF-1 level was low at 105 and thyroid tests were normal.  Bone age essentially matched the chronological age at 9 years. Records from one year ago indicate a height at the 3-5th percentile and a projected adult height of 55` (according to the non-retarded table in the Gleulich and Pyle wrist and hand atlas). A more recent bone-age study was read as retarded, which would imply an improving height prediction. The growth rate curves for some years appeared to be normal along the lower percentiles, however there were short-interval measurements last year that suggest a decreased height velocity of 2.4 cm per year.A request has been made for initiation of growth hormone therapy, which has been denied by the Health Plan. At issue is whether the requested therapy is medically necessary for treatment of the patients condition.The submitted records did not include the heights of the parents or make reference to birth history with weight and length measurements. In general, the height velocity measurements provided were inadequate to accurately judge the actual growth rate over time despite data for one short interval. There were no references in the submitted materials to a workup for other causes of short stature, and the record lacked data on pubertal development status. Thus, there is insufficient evidence growth hormone therapy is medically warranted at this time. If, however, future growth measurements better document an actual growth retardation and demonstrate a significant deficit in adult height prediction (with respect to the parent's height), the issue of growth hormone treatment should be revisited.On the basis of the information provided, I have determined that the requested therapy is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

The parents of a 10-year-old male enrollee have requested  for inpatient neuropsychiatric hospital stay for treatment of the enrollees bipolar disorder.  Findings:  The physician reviewer found that the differential diagnosis for this patient includes Bipolar Disorder or a primary Psychotic Disorder on the order of Schizophrenia. Certainly, the manner of treatment which proved at least somewhat effective could well span either diagnostic consideration.  However, to the extent that the patient was quite impaired (and his home environment unstable), some manner of extended time in an inpatient setting to ensure the patients improvement was imperative.
Appeal type: Experimental/Investigational
Decision: Upheld

A 51-year-old female has requested coverage for past re-exploration of the right occipital nerve and takedown of arteriovenous malformation, subcutaneous for treatment of her residual occipital nerve compression.  Findings:  Two physician reviewers found that the patient presents with diagnoses including migraine headaches, neck pain, occipital neuralgia, complex regional pain syndrome (CRPS), and trapezius spasm. Records and patient letter indicate that she has had continuous skull base pain, and has been treated with prior occipital nerve release with persistent pain, and has had modalities, facet and nerve blocks, and various medications without success. The physical examination notes do not include neurologic examination findings, head and neck examination, or indication of occipital neuralgia. She underwent re-exploration of the right occipital nerve, with the operative report stating that there was arterial compression of the right occipital nerve.  The records in this case suggest a patient with chronic migraine. Chronic migraine is often associated with posterior pain. The peer-reviewed medical literature suggests that occipital neuralgia and cervicogenic headaches are frequently misdiagnosed, when the correct diagnosis is chronic migraine. She has had prior procedural interventions, with only temporary relief. Botox treatment is considered the standard of care, and proven to be effective for chronic migraine. Occipital nerve decompression surgery has been previously performed with inadequate benefit, and then was repeated. Overall, there is a paucity of adequately designed randomized placebo-controlled trials supporting this intervention. All told, nerve decompression surgery is not likely to be more beneficial than standard therapies in managing this patients medical condition. The patient has not had the advantage of a trial of Botox treatment, to be repeated at least once, at three-month intervals.
Appeal type: Medical Necessity
Decision: Upheld

The patient has requested authorization and coverage for Adderall 35 mg and alprazolam 1 mg. Researchers noted that stimulant medications, such as Adderall must be used with great care if there is a history of drug abuse. They are contraindicated in patients with a history of illicit use or abuse of stimulants, unless the patient is being treated in a controlled setting or can be supervised closely. In this case, the patient has a history of multiple chronic mental illnesses and longstanding amphetamine misuse. While his providers have attempted to arrange intensive behavioral treatment and medication management, the patient has wavered between a desire to stop using stimulants and a wish to receive Adderall for treatment of possible ADHD symptoms. This patients providers recommended behavioral approaches to address both his stimulant use disorder and his other mental health issues, including intensive outpatient treatment. The patient did not attend these programs consistently. Given the patients recent history of stimulant use disorder, Adderall 35 mg is contraindicated. Likewise, given the chronicity of the patients anxiety symptoms and history of substance misuse, alprazolam 1 mg is contraindicated. Therefore, Adderall 35 mg and alprazolam 1 mg are not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested medications 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 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 20-year-old male enrollee requested intravenous immune globulin (IVIG) treatments for treatment of his  pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAS).  Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the requested IVIG therapy. Hoekstra and colleagues studied 30 patients with tic disorder who were randomly treated with IVIG and placebo. The authors found no significant differences between both treatment groups regarding post treatment changes in tic severity. The authors concluded, Based on the present results, IVIG cannot be recommended in tic disorders. This patient has been diagnosed with PANDAS, based on tics, OCD symptoms, history of prior strep infections, and elevated ASO titer. Although the patient appears to meet the diagnostic features of PANDAS, there is a lack of support in the peer-reviewed literature of the effectiveness of IVIG in this clinical setting. All told, the medical necessity of the requested services has not been established in this clinical setting.
Appeal type: Experimental/Investigational
Decision: Upheld

A 55-year-old female enrollee has requested for a bilateral breast MRI for evaluation of the enrollees medical condition.   Findings:  Two physician reviewers found that this patient with no reportable family history of breast cancer and no other risk factors, an MRI is not demonstrated to have a role in this type of clinical situation per the current literature. In terms of this patients history of chest wall carcinoma, there was no reported chest wall radiation, and the chest wall carcinoma, in and of itself, is not a risk factor for breast cancer.
Appeal type: Experimental/Investigational
Decision: Overturned

The parents of a nine-year-old male enrollee have requested for comprehensive computerized motion analysis testing and electromyography testing for treatment of the enrollees gait disorder. Findings:  Three physician reviewers found that pre-surgical assessment of the deformity requires three-dimensional motion, force and electromyographic analysis of the patients gait. This allows accurate measurements of the many gait parameters required for precise correction of gait problems at multiple levels. Various clinical studies and publications have shown computerized gait analysis to be far more accurate and precise than visual assessment. It gives three-dimensional views at multiple joints and planes and allows for multiple level surgical interventions in one operation. The older method is a trial and error approach, resulting in over-and under-corrections and often requiring multiple surgeries to correct problems at a single level.
Appeal type: Medical Necessity
Decision: Upheld

A 21-year-old female enrollee has requested Xyrem for treatment of her insomnia. Findings:  The physician reviewer found that the patient has a chronic pain syndrome with refractory insomnia. According to the manufacturer prescribing information, Xyrem has been approved by the U.S. Food and Drug Administration (FDA) to reduce daytime sleepiness and cataplexy in patients with narcolepsy. Xyrem has not been approved by the FDA for the treatment of insomnia. At this time, there is a lack of peer-reviewed evidence supporting the use of Xyrem for the treatment of chronic insomnia. In the absence of scientific data demonstrating the safety and efficacy of Xyrem for individuals with insomnia, the medical necessity of Xyrem for this patient is not established.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:   An enrollee has requested intravitreal Avastin injections for treatment of her medical condition.  Three physician reviewers found that the current medical evidence supports the services at issue in this clinical setting.  Avastin has a proven role in treating other exudative retinal diseases, and there are case studies of beneficial treatment in the setting of non-exudative macular disease such as macular telangiectasia.  There is no standard treatment for macular telangiectasia, and the disease often does not respond to medical or surgical treatment.  In this case, the patient has cystoid macular edema and pigment epithelial detachment likely related to macular telangiectasia. All told, intravitreal Avastin injections and future intravitreal Avastin injections were and are likely to be of greater benefit than other treatment alternatives.  Final Result: Three reviewers determined that the services at issue were and are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: All three 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: Experimental/Investigational
Decision: Overturned

A female enrollee requested a small drain placed (CPT 0191T) during eye surgery for medical treatment of her glaucoma.  Findings:  Two physician reviewers found that current peer-reviewed medical literature and this patients records support the use of the small drain placed (CPT 0191T) during eye surgery as likely to have been more beneficial for treatment of the patients medical condition than any available standard therapy.