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

Nature of Statutory Criteria/Case Summary:  An enrollee has requested partial hospitalization program services for treatment of her behavioral health condition. Findings:  The physician reviewer found that the initial treatment services could not have reasonably been conducted at a less restrictive setting because the patients prominent occupational, financial and parenting stressors had not resolved.  She remained symptomatic, documentation noted that she was making limited progress in her therapy groups, and was described as agitated, anxious and depressed in group.  The provider described the patient as dysphoric and anxious.  In sum, the patient had not yet consolidated the treatment gains necessary to succeed in the outpatient setting. Thereafter the patient made slow but steady progress.  The patient still struggled in the mornings and expressed her dislike of being alone; however, progress notes indicated that she felt better: she was more motivated; she had more energy; and her mood improved.  The records also reflect that her anxiety and OCD symptoms had decreased. At this time, she was sleeping better and her family had been involved in her treatment and was supportive. The records show that she was tolerating her medications well and had a modest dose reduction of one of her medications. Based on the documentation provided, discharge to a less restrictive setting at this point would have been safe, appropriate and consistent with good medical practice.  Upon review of the patients documentation, the patient initially benefitted from partial hospitalization program services.  However, partial hospitalization program services provided thereafter were no longer medically necessary for the treatment of this patient.  Final Result: The reviewer determined that a portion of the services at issue was medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned.  Credentials/Qualifications: The reviewer is board certified in psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A female enrollee requested authorization and coverage of physical therapy.  The Health Plan denied the request indicating that the requested therapy is not medically necessary for treatment of the enrollees degenerative joint disease.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested therapy is not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

A 44-year-old male enrollee has requested for 93 external self-adhesive condom catheters (ESACC) per month for treatment of the enrollee, who is a quadriplegic with a history of recurrent urinary tract infections. Findings:  The physician reviewer found that a condom catheter must be removed in order to perform self-catheterization. A condom catheter applies to the penis with an adhesive which is part of the condom. This seal is lost when the condom catheter is removed, and it cannot be successfully reapplied. The patients providers have recommended self-catheterization three times per day. Thus, 93 external self-adhesive condom catheters per month are medically indicated, as a new condom should be attached after each self-catheterization. In this patients case, the requested quantity of 93 external self-adhesive condom catheters per month is needed to keep dry and hygienic and to manage urinary collection.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for systemic hyperbaric oxygen therapy (HBOT). The U.S. Food and Drug Administration (FDA) has not approved HBOT for the treatment of patients with SSNHL. Systematic reviews have reached discordant conclusions about the effectiveness of HBOT. In this case, the available clinical documentation did not demonstrate initial steroid therapeutic failure. In addition, no follow-up audiogram was documented to determine the hearing thresholds following treatment with steroid therapy and prior to starting HBOT. Given these findings, the requested systemic HBOT is not 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 that the requested systemic HBOT is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewer 1 is board certified in family practice with subspecialty certification in undersea and hyperbaric medicine and is actively practicing. Physician reviewer 2 is board certified in otolaryngology and is actively practicing. Physician reviewer 3 is board certified in otolaryngology 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Orencia. This patients provider has recommended treatment with Orencia to address diagnosis of systemic lupus erythematosus (SLE) with secondary antiphospholipid antibody syndrome. The reviewed records indicate that the patients SLE is stable, but there is concern for persistently elevated lupus anticoagulant and anticardiolipin. Steroid sparing therapy with Orencia is not indicated for the treatment of positive lupus anticoagulant and anticardiolipin. Although arthralgias and myalgia is reported, on physical examination there were no synovitis or joint tenderness noted to specifically support the use of Orencia. Medical literature shows that Orencia failed to meet its primary endpoint, time to complete response, in a phase II/III trial as an adjunct treatment for class III or IV lupus nephritis. There are several standard medications recommended for the treatment of patients with SLE that serve as steroid sparing agents including azathioprine, CellCept, Benlysta, and Saphnelo. The medical records do not document that this patient has been treated with and failed to improve with the recommended agents that have been demonstrated to be safe and effective in the peer-reviewed medical literature. In conclusion, the requested Orencia is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: The reviewers determined that the requested medication 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: Physician reviewer 1 is board certified in internal medicine with subspecialty certification in rheumatology and is actively practicing. Physician reviewer 2 is board certified in internal medicine with subspecialty certification in rheumatology and is actively practicing. Physician reviewer 3 is board certified in internal medicine with subspecialty certification in rheumatology 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: Experimental/Investigational
Decision: Overturned

The parent of a 13-year-old female enrollee requested or laboratory testing including immune cell function assay for medical evaluation of the enrollees liver transplant.  Findings:  Three physician reviewers found that this assay has been approved by the US Food and Drug Administration (FDA) for immune monitoring functions. In addition, the laboratory testing at issue is FDA approved for monitoring immune function in a transplant patient in this clinical setting. The safety and efficacy have been established in the medical literature and its utilization is considered a standard of care protocol in some transplant centers. Consistent with this support, the testing at issue was likely to have been more beneficial than any available standard therapy.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for occipital nerve blocks for treatment of the enrollees chronic migraines. Findings:  The physician reviewers found that the efficacy of greater occipital nerve blocks in the management of chronic migraine remains uncertain. There are conflicting data concerning treatment response for this procedure. At this time, it is not considered to be an accepted standard of care or treatment. Prophylactic/preventative medications for migraine remain more appropriate treatments. Therefore, occipital nerve blocks were not likely to have been more beneficial than standard therapy in this patients case. Final Result: Two of three reviewers determined that the services at issue were 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: Physician reviewers number one, two, and three are board certified in neurology and 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: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the FoundationOne test for evaluation of the enrollees left hilar mass. Findings:  2/3 of the physician reviewers found that Foundation One is a molecular assay that explores the mutations of an individual patients cancer cells. The goal of the assay is to identify a specific mutation or target which could guide the provider as to which chemotherapeutic agent would be useful. However, there is a paucity of evidence that the Foundation One assay adds to decision making ability, or yields a result that is reliably clinically beneficial. There are non-randomized studies exploring the value of molecular profiling, but the results have not been convincing as to the efficacy of such an approach to treatment. A randomized trial did not demonstrate a significant clinical benefit from choosing therapy based on molecular targets versus by the providers clinical judgment. Currently, the data suggests that finding a mutation does not support treatment directed at that target to produce a clinically meaningful response. All told, the Foundation One test provided was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: 2/3 of the 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: Physician reviewer number one is board certified in internal medicine with sub-specialty certification in medical oncology 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.Physician reviewer number two is board certified in internal medicine with sub-specialty certification in medical oncology 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.Physician reviewer number three is board certified in internal medicine with sub-specialty certification in medical oncology 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 66-year-old male enrollee requested for a Microgyn Pelvic Floor Stimulation Unit for treatment of his urinary incontinence.   Findings:  Three physician reviewers found that there is no accepted body of literature or scientific papers which have shown pelvic floor stimulation and devices to produce the same or better than time alone in restoring continence. The alternatives therapies currently accepted for treating male incontinence in the post-operative period are waiting for spontaneous resolution and artificial urinary sphincter and male sling procedure when that fails to occur. Many cases do persist as very minor leaks with stress maneuvers such as coughing, laughing, and sneezing. These are generally managed by a small absorptive pad. Anti-cholinergics with specific bladder selectivity are also used (and were used in this case).
Appeal type: Medical Necessity
Decision: Overturned

An enrollee has requested authorization and coverage for lumbar/sacral facet joint radiofrequency neurolysis on the right side.Medical literature supports that the requested services are medically necessary. The American Society of Interventional Pain Physicians (ASIPP) has stated in evidence-based guidelines that the evidence for therapeutic facet joint interventions is good for conventional radiofrequency. In this case, the patient has low back pain due to lumbar degenerative disc disease and previously had successful right lumbar radiofrequency ablation treatment which provided greater than 70% relief that lasted for more than 6 months. The patient more recently had the left side of her lumbar spine treated with a radiofrequency ablation which provided greater than 70% pain relief. The patient has already completed physical therapy within the last 6 months and is continuing with a home exercise program. Based on the current national ASIPP guidelines, a patient may undergo a repeat lumbar radiofrequency ablation if they reported at least 50% relief for at least 6 months, which is the case for this patient. Furthermore, the patient has participated in appropriate conservative treatment measures and is active in a home exercise program. The request for a repeat procedure is reasonable and consistent with the current national guidelines regarding the indications for this procedure. Under these circumstances, the requested lumbar/sacral facet joint radiofrequency neurolysis on the right side is medically necessary to treat 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 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollees parent has requested reimbursement for wilderness therapy services the enrollee received at Pacific Quest. Current medical literature suggests that wilderness therapy may be an effective treatment option for a wide variety of adolescents, including youth with substance abuse problems and adolescents suffering from depression and various other clinical disorders, and may improve interpersonal relationships. However, there is a lack of evidence supporting the claim that outdoor behavioral healthcare programs are superior to standard therapies as a treatment intervention for adolescent substance use and mental health disorders. Few studies directly compare outcomes of outdoor behavioral healthcare programs to other therapeutic interventions. Dobud and Harper note that in a scoping review of direct comparison trials in adventure therapy, only 13 studies met the full inclusion criteria. The authors found few significant differences to isolate specific therapeutic factors. While literature on outdoor behavioral healthcare programs suggest that participants show some level of improvement on behavioral health outcomes, the results are not conclusive. There is a lack of randomized controlled trials or well-designed cohort studies that would allow for causal conclusions about the impact of outdoor behavioral healthcare programs. In this clinical setting, there is a lack of data to support the claim that outdoor behavioral healthcare programs were more effective than other therapies. Therefore, wilderness therapy services the patient received at Pacific Quest were not likely to have been more beneficial for treatment of the patient's condition than any available standard therapy.Findings:  Three of the three physician reviewers found the wilderness therapy services the enrollee received at Pacific Quest were not likely to have been 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 not likely to have been more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewers 1, 2, and 3 are board certified in psychiatry with sub-specialty certification in child and adolescent psychiatry 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: Upheld

A 34-year-old male enrollee has requested tamsulosin (Flomax 0.4mg)for treatment of his benign prostate hyperplasia. Findings:  The physician reviewer found that alpha blockers are the appropriate treatment for benign prostate hyperplasia symptoms (e.g., urgency, frequency, nocturia and slow stream). There are two types of medications known to be effective in the treatment of benign prostate hyperplasia  alpha blocking medications, which relax the nerves that tighten the bladder neck and 5-alpha reductase inhibitors, which block the transformation of testosterone to dihydrotestosterone. The alpha blocking medications usually work faster than the 5-alpha reductase inhibitors. In this case, the patient wishes to be treated with the alpha blocker, Flomax. The Health Plan recommends alternative alpha blockers such as doxazosin, terazosin or prazosin. Although Flomax is a newer drug than the medications offered by the Health Plan, all of the drugs are effective for the treatment of benign prostate hyperplasia. Furthermore, there is no evidence demonstrating that use of the Health Plan alternatives are contraindicated in this patient. The medical records do not reveal that the patient has any condition that would necessitate the use of Flomax as a first-line therapy. As such, the medical necessity of Flomax has not been established.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  The parent of an enrollee has requested authorization and coverage for acupuncture services. Findings:  The physician reviewer found that Vickers and colleagues state, Acupuncture is effective for the treatment of chronic musculoskeletal, headache, and osteoarthritis pain. Treatment effects of acupuncture persist over time and cannot be explained solely in terms of placebo effects. Referral for a course of acupuncture treatment is a reasonable option for a patient with chronic pain. Additionally, Kelly and Willis state that for certain patients who are experiencing pain, especially those who are unresponsive or intolerant to standard therapies, acupuncture is a reasonable treatment option. Moreover, a review by Zhang and colleagues found, There is growing evidence that acupuncture is just as effective and has fewer side effects than many of the standard pharmaceutical agents that are currently used. In this case, the patient has not undergone an acupuncture trial. Given the patient continues to be significantly symptomatic, with severe pain levels that remained unchanged despite prior treatment modalities, the requested acupuncture is medically reasonable and supported by the peer-reviewed literature. Therefore, acupuncture services are medically necessary for the 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 oriental 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

A female enrollee requested Namenda XR (memantine HCl Cap. SR 24HR) 28 mg for medical treatment of her Alzheimers disease.  Findings:  The physician reviewer found that this patients records suggest the patient is having significant recent memory issues, and now requires help from the family to take her medications, cook, and take care of her more complex, but not basic needs. According to the Alzheimers Association, this patients symptoms support a diagnosis of moderate Alzheimers, which supports the use of Namenda.  All told, the requested Namenda XR (memantine HCl Cap. SR 24HR) 28 mg is medically necessary for treatment of this patients medical condition.