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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for periodontal scaling and root planning, billed as CPT code D4342, to LR tooth or quad, and periodontal scaling and root planning, billed as CPT code D4341, to UR tooth or quad for treatment of the enrollees periodontitis. Findings:  The physician reviewer found that the records including the patients perio-charting and x-rays do not support an indication for periodontal scaling and root planning. The provider noted the patients pocket depths range from 3-5 mm. There is no documentation of bleeding on probing, clinical attachment loss, or the presence of sub-and or supra-gingival build-up to support periodontal scaling and root planning. All told, the periodontal scaling and root planning, billed as CPT code D4342, to LR tooth or quad, and periodontal scaling and root planning, billed as CPT code D4341, to UR tooth or quad were not dentally necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the services at issue were not dentally necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in oral and maxillofacial 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

A 19-year-old female enrollee has requested inpatient hospitalization services for treatment of her bulimia and depression, not otherwise specified. Findings:  The physician reviewer found the submitted documentation fails to demonstrate the medical necessity of the services at issue.  Per the submitted documentation, acute hospitalization was initially indicated for her chronic mood symptoms and persistent eating disordered behavior despite intensive outpatient programming.  However, the medical records do not support the medical necessity of the admission during the specified time.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Ubrelvy (ubrogepant) 100 mg tablets. The U.S. Food and Drug Administration (FDA) describes Ubrelvy (generic name ubrogepant) as a calcitonin gene-related peptide receptor antagonist indicated for the acute treatment of migraine with or without aura in adults. In a randomized trial to evaluate the efficacy, safety, and side-effect profile of ubrogepant, Dodick and colleagues concluded that a higher percentage of participants who received ubrogepant than of those who received placebo had freedom from pain and absence of the most bothersome symptom at two hours after the dose. In this case, the patient has chronic migraines and has tried and failed a combination of abortive and prophylactic therapies. Given current medical literature, the requested medication is medically indicated. Therefore, Ubrelvy (ubrogepant) 100 mg tablets are medically necessary for the 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 neurology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a bariatric surgeon consultation. The Health Plan has denied this request indicating that the requested service is not medically necessary for treatment of the enrollees morbid obesity. A review of the record indicates that the enrollee has been diagnosed with schizoaffective disorder bipolar type; asthma; alcohol use disorder; hypertension; diabetes; and morbid obesity. A progress note dated 7/27/18, reported the enrollee presented for a psychiatric evaluation for gastric bypass procedure. The provider reported the enrollee had tried multiple diets, diet pills (Hydroxycut), and exercises regularly without losing significant weight. The enrollee denied binge eating and purging. The provider reported the enrollee was mentally stable enough to have the procedure and participate in necessary follow up. At issue in this case is whether the requested bariatric surgeon consultation is medically necessary for treatment of the enrollees medical condition. Clinical practice guidelines indicate that adults with a body mass index (BMI) between 30.0 and 34.9 and either uncontrolled diabetes type two or metabolic syndrome may be candidates for this surgery. The following conditions are contraindications to bariatric surgery: untreated major depression or psychosis; uncontrolled eating disorder such as bulimia; current drug and alcohol use; severe cardiac disease with prohibitive anesthetic risk; severe coagulopathy; and inability to comply with post-operative life-long mineral replacement. The patient requests a surgical consultation for bariatric surgery. Based on the clinical practice guidelines, bariatric surgery is justifiable in a patient with a BMI of 35.0 to 39.9 with at least one major complication and a BMI of 40 without major complications. This patient has a BMI of 44.6. Diabetes and mental health issues complicate her obesity. Although this patient has documented schizoaffective disorder and alcohol abuse disorder, both are under control either in treatment or with medication. Bariatric surgery is a consideration for patients who have failed to improve with diet; counseling; exercise; and pharmacologic treatment. The patient is noted to have failed all of these conservative modalities. The patient has met guideline criteria for this surgery and therefore, the request for a bariatric surgeon consultation is medically necessary. Final Result: The reviewer determined that the requested services 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 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 parent of an enrollee has requested intravenous immune globulin (IVIG) therapy. Findings:  The physician reviewer found that PANDAS is a disorder with early and abrupt onset of obsessive-compulsive disorder (OCD) and/or tic disorders subsequent to streptococcal infections. PANDAS is a clinical diagnosis and is suspected in children with an abrupt onset of neuropsychiatric symptoms, recent group A streptococcal (GAS) infection, and remission of neuropsychiatric symptoms with antibiotic therapy. In this case, the clinical evidence submitted for review supports the treatment of IVIG for this patient. Perlmutter and colleagues performed a randomized control trial. The potential benefits of treatment with plasma exchange or IVIG was compared with placebo in 29 children who met PANDAS criteria and were severely affected. Symptom severity was rated at baseline, and at 1 and 12 months after treatment. Significant improvement in symptoms from baseline was noted in the treatment groups at one month and improvements were maintained at one year. In conclusion, the IVIG therapy at issue was medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the therapy at issue was 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 allergy and immunology 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: The patient has requested authorization and coverage for Linzess 290 mcg. The U.S. Food and Drug Administration (FDA) has approved the use of Linzess for the treatment of patients with chronic idiopathic constipation. The current American Gastroenterological Association (AGA) guidelines for the treatment of constipation recommend the use of osmotic and then stimulant laxatives before advanced agents such as Linzess. This patients records document a history of chronic constipation, diverticulitis, and abdominal pain, as well as small bowel obstruction. Although the patient has constipation, the documentation does not report failure of safe, effective initially recommended over the counter laxative alternatives to support an indication for treatment with Linzess. Moreover, the U.S. Food and Drug Administration (FDA) approved prescribing information states that Linzess is contraindicated in patients with known or suspected mechanical gastrointestinal obstruction. In this case, the patient was reportedly admitted and treated for small bowel obstruction. For these reasons, the requested Linzess 290 mcg is not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in internal medicine with 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: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  The parent of the patient has requested reimbursement for residential treatment center services. The American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists Child and Adolescent Level of Care Utilization System (CALOCUS) provides a reliable framework for determining the appropriate level of care for adolescents needing mental health treatment. Using CALOCUS, treaters score patients on a scale of 1-5 using a six-pronged Dimensional Rating System. The six dimensions include: (1) risk of harm; (2) functional status; (3) medical, addictive and psychiatric comorbidity; (4) recovery environment (a. stressors and b. supports); (5) treatment and recovery history; and (6) engagement. The composite score is then used to determine the level of care needed. Per CALOCUS, RTC level of care requires a composite score of at least 23.Regarding the six CALOCUS dimensions, the patient has a low risk of harm; the records do not indicate he was suicidal (score = 2). Regarding functional status, the patient has had some issues with level of functioning due to mental illness and relational issues, but overall showed appropriate daily functioning while in treatment (score = 2). Regarding comorbidities, the patients past medical issues did not appear to adversely impact him during the disputed days of service (score = 2). The patient was noted to have interpersonal conflict with family members due to his running away from home; however, the progress notes document that his relationship and family sessions were productive and not adversarial (score = 2) and the patients parents are involved and supportive (score = 2). With respect to treatment success, the patient had an aggressive outburst during a recent short stay at an RTC. For the dates of service at issue here, however, the patient was participating in therapy programming and did not display any serious or disruptive symptoms (score = 3), participated in therapy and was cooperative with consistent engagement (score = 2) and has parents who work actively and constructively with clinicians (score = 2). For a CALOCUS composite score of 17, the recommended level of care is high-intensity outpatient therapy. Therefore, the RTC services were not medically necessary for this patient.Final Result: The reviewer determined that the services at issue were not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in psychiatry with subspecialty 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for genetic testing for evaluation of the enrollee who presented for prenatal care. Findings:  The physician reviewers found there is support in the medical literature for a portion of the services at issue in this clinical setting.  The NIPT testing was an indicated procedure for this patient because she would be over 35 years old at the time of delivery. Patients who are 35 years of age or older at the expected time of delivery are considered in a high risk setting. The American College of Obstetricians and Gynecologists Committee (ACOG) endorses the discussion and use of NIPT testing in this patient population. In this case, the patient elected to have NIPT testing performed and her results were normal. With regards to the additional screening, there is a lack of support in the documentation provided for this portion of the genetic testing. Fetal sex determination in a patient without evidence of sex linked specific risk factors are not indicated. Current guidelines from the ACOG recommend prenatal screening and genetic counseling for fragile X in women with a family or personal history of fragile X, unexplained mental retardation or developmental delay, or premature ovarian insufficiency. In addition, ACOG recommends that all women who request fragile X carrier screening be offered DNA testing after appropriate genetic counseling. Testing for these genetic disorders is usually directed at patients with a specific family history or particular ethnicity. The records submitted do not document any specific risk factors for this patient. Typically, the recommendation is based on being of Ashkenazi Jewish heritage or having a relative or previously affected infant, with one or more of the tested conditions. Additionally, if a fetus is demonstrating one or more major structural anomalies on ultrasound screening, this would be considered an indication for the additional tests. These conditions do not appear to be present in this patients case. As such, the NIPT testing done for trisomy screening was likely to have been of greater benefit than the other methods of screening this patient. However, the genetic screening for additional disorders and fetal sex determination were not likely to have been more beneficial than the standard options for the evaluation of this patient. Final Result: Two of three reviewers determined that a portion of the services at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be partially overturned. Credentials/Qualifications: Physician reviewer number one is board certified in obstetrics and gynecology 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: Overturned

An 18-year-old female enrollee has requested for partial hospitalization for treatment of her bulimia nervosa. Findings:  The physician reviewer found that she continued to have significant symptoms, including anxiety and dysphoria.  This patient would most likely have deteriorated in mood, eating disorder symptoms, and anxiety symptoms without this continued level of care.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for brand name Minivelle transdermal patch. As noted by the North American Menopause Society (NAMS), there are many options for estrogen for hormone replacement that have been demonstrated in the clinical studies to be equally effective. Transdermal estrogen is reported to have the lowest potential for increased risk of thrombosis, which the patient noted is a concern given her treatment with a blood thinner (Bergendal, et al.). The patient reports that she can tolerate brand name Minivelle, but other hormone replacement therapies have caused side effects. However, there are alternative transdermal estrogens available for treatment of this patient. In addition, there are no primary source treatment records to document that the patient has completed an adequate trial to, or has been intolerant of, other estrogen options available for hormone replacement in the setting of menopause. All told, the brand name medication Minivelle transdermal patch was not and is not medically necessary for treatment of this patient. Final Result: The reviewer determined that the medication at issue was not and 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 obstetrics and gynecology 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 28-year-old female enrollee has requested serum testing for infliximab (Serum IFX) for evaluation of her ulcerative colitis. Findings:  Two physician reviewers found that the loss of response to infliximab can be due to sub-therapeutic infliximab (IFX) levels or the presence of antibodies to infliximab (ATI). While more research is needed, the available data suggest that measuring drug and/or antibody levels can help providers optimize anti-tumor necrosis factor (TNF) therapy by adjusting drug doses or switching to alternative therapies in patients who are unlikely to respond to continued treatment with a particular agent. Data suggests that in patients with Crohns disease and ulcerative colitis treated with scheduled maintenance infliximab infusions, the trough serum concentration of infliximab predicts clinical outcome. For these reasons, measuring both IFX and ATI concentrations may help guide patient management and are likely to be more beneficial in evaluating and treating this patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 43-year-old male who has significant coronary artery disease (CAD) and has had two stents placed. His cardiologist indicates he is in the high risk group, and has established a target LDL of less than 70 mg/dL. The patient was prescribed Lipitor 80mg in March 2006 but was functionally taking Lipitor 40mg. At that time Zetia was added to his medication regimen. Follow-up testing in April 2006, while on Lipitor 40mg daily and Zetia 10mg daily, indicated the patient had achieved his target LDL (61 mg/dL). He began a trial of Vytorin 10/80 in May of 2006 and his LDL was off target in June 0f 2006 (113 mg/dL). The patients request for authorization of Zetia was denied by the Health Plan citing a lack of medical necessity.This is a patient with known CAD for whom achieving and maintaining the declared LDL target of less than 70 mg/dL is very important. He did indeed demonstrate a failure of Vytorin and a change from Lipitor 40mg to Lipitor 80mg is unlikely to result in a decrease in LDL of 40 points or greater. As there is no data indicating the superior efficacy of Crestor, a trial of Crestor after treatment failures with Lipitor alone and Vytorin is not consistent with the standard of practice among specialists in cardiovascular disease. Given the demonstrated reduction in the patients LDL to 61 mg/dL while taking Lipitor and Zetia, I would support the continued need for treatment with Zetia and high dose Lipitor as prescribed by his cardiologist.Based upon the information set forth above, 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

A 27-year-old female enrollee has requested reimbursement for intensive outpatient program (IOP) for one month and continued authorization for IOP services from a specific date and onward for treatment of the enrollees multiple mental health conditions. Findings:  The physician reviewer found that The patient had not consolidated the treatment gains necessary to succeed in less restrictive setting by the first date of the IOP.  Indeed, the patient was unable to negotiate stressors that led to an acute hospitalization. But, prior to that, the patient was enduring persistent problems related to her acute crisis that prompted IOP placement.  Further, she was having difficulty managing boundaries and was relying on self-defeating coping strategies, such as drinking, to alleviate her intrapsychic discord.  Finally, she was residing in a chaotic environment that was not conducive to recovery.  Thus, the IOP services provided were medically necessary for the treatment of the patients medical condition.  Continued authorization for IOP services, provided from the date in question and onward, were not and are not medically necessary for the treatment of the patients condition.  Psychiatrically, the patients medication regimen does not exceed a level of complexity appropriate for routine outpatient care and there are no unresolved medical issues which might support placement at the IOP level of care.  In reviewing the therapy notes, the patient was consolidating the concepts of mindfulness and cognitive behavioral therapy, while developing proficiency in an array of coping skills such as guided imagery, experiential relaxation, deep breathing, counting and praying.  She received positive feedback from her group cohort and although she continues to need work on core issues, there is no evidence provided in the record that IOP services are medically necessary for the patient to achieve these goals. Therefore, as of the date in question, services were not and are not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

A 52-year-old female enrollee requested authorization and coverage of Peginterferon with Ribavirin. The Health Plan  denied the request indicating that the requested therapy is not medically necessary for treatment of the enrollees hepatitis C.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.