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

A 51-year-old male enrollee requested authorization and coverage of a mitral valve repair with pericardial strip annuloplasty as opposed to prosthetic ring insertion. The Health Plan denied the request indicating that the requested procedure is not medically necessary for the treatment of the enrollees mitral valve regurgitation.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested procedure is not medically necessary.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested digital breast tomosynthesis for evaluation of the enrollees breast cancer screening.  Findings: Two physician reviewers found that Tomosynthesis is a technique that was developed as a problem solving adjunct to routine mammography. In this case, the presence of implants alone does not constitute a definite indication for tomosynthesis. However, the patient has breasts that have been described as heterogeneously dense. While one could make the argument that her mammogram has not changed since the last study, it is specifically those patients who have dense breasts that can benefit most from tomosynthesis. The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor. Accordingly, the digital breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: Two reviewers determined that the diagnostic procedure 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 overturned.Credentials/Qualifications: All three physician reviewers are board certified in diagnostic radiology and are actively practicing. The reviewers are 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

The parent of a 15-year-old female enrollee has requested psychiatric subacute residential treatment for  the enrollees mood instability and family conflict.  Findings:  The physician reviewer found that current standards of psychiatric practice recommend placement of patients in the least restrictive treatment setting. In general and if feasible, community intervention settings are thought to offer optimization of treatment gains. However, determining the appropriate level of care for adolescent patients with psychiatric conditions and family conflict depends on multiple factors and unique considerations. According to the American Academy of Child and Adolescent Psychiatry (AACAP) Practice Parameter for depression, the clinician, together with the child and parents, should evaluate the appropriate intensity and restrictiveness of care (e.g., hospitalization). The decision for the level of care will depend primarily on level of function and safety to self and others, which in turn are determined by the severity of depression, presence of suicidal and/or homicidal symptoms, psychosis, substance dependence, agitation, childs and parents adherence to treatment, parental psychopathology, and family environment. Ultimately the interpretation and application of clinical guidelines and patient placement criteria falls upon physicians and therapists working directly with the patient population.  In this particular case, the treating team with the best knowledge of the patient, such as her therapeutic tasks, developmental limitations and available support systems, deemed the patient to be incomplete in the consolidation of treatment gains necessary to succeed at a less restrictive setting by date indicated. This is consistent with the literature as meaningful treatment takes time. Indeed, per the Dulcan Text: Longer duration of treatment is associated with several favorable outcomes. Therapeutic efforts during the disputed time frame were aimed at improving insight and defenses while facilitating a smooth transition to a less restrictive setting. For example, although feeling better on the date indicated, the patient clearly demonstrated mood lability and depressed feelings while a family session the following day focused on a particularly stressful recurrent situation. The patients formidable history of affective dysregulation coupled with negative schemas, unrefined coping strategies, family system issues and psychosocial stressors unique to her case, would have more than likely undermined treatment efforts at a lower level of care during that time, thus burdening the patient with unnecessary morbidity and risk for readmission. In conclusion, the services at issue were medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested partial hospitalization program (PHP) level of care for treatment of her behavioral health condition. Findings: The physician reviewer found that the medical records indicate that the patient did not receive an adequate amount of supervision and support when she was stepped down from PHP to IOP.  Her coping skills were not sufficiently developed for her to deal with the stressors she encounters on a daily basis.  There are clear signals that she has been relapsing and requires treatment at the present level of care.  The treatment teams decision to increase the intensity of services and transfer the patient back to PHP level of care was medically appropriate and indicated in light of her prior response to treatment at that setting. Continued treatment at the PHP level is warranted given the patients ongoing symptomatology. Based on the submitted documentation, PHP level of care is reasonable and medically necessary for treatment of this patients behavioral health condition.Final Result: The reviewer determined that the services at issue were and 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 psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for palatopharyngoplasty with a partial glossectomy. The records provided for review document that this patient has been unable to tolerate treatment with CPAP. As noted by the provider, due to the patients upper airway obstruction, treatment with CPAP requires a high level of pressure. This high pressure results in abdominal symptoms from swallowed air. Additional treatment with a mandibular advancement device worsened the patients TMJ symptoms. Physical examination revealed a retroplaced tongue consistent with Mallampati 3. Given the failure to improve with CPAP and an oral device, palatopharyngoplasty and partial glossectomy are reasonable treatment options given this patients anatomy. Thus, the requested palatopharyngoplasty with a partial glossectomy are supported as medically necessary for treatment of this patients OSA. 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 otolaryngology 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 physical therapy services. Medical literature note that the Department of Health and Human Services physical activity guidelines for Americans recommend that people with chronic conditions remain physically active as their abilities and conditions allow. In this case, the records note that the patient was discharged from physical therapy following completion of interventions and reaching his maximum potential. The patient is limited in the physical activity he can tolerate due to his chronic illnesses, and the recommendation in this clinical setting is to maintain levels of function as allowed, such as bed mobility and sit to stand transitions.  While researchers note that aerobic and resistance exercise may potentially benefit patients with obesity, such therapies may be provided by caregivers as a home exercise program. Given that the patients current goal is to maintain his status through caregiver or certified restorative nurse (CRN) assistance, current medical literature does not support the use of professional physical therapy services. Therefore, physical therapy services are not medically necessary for the 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 board certified in physical medicine and rehabilitation 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 52-year-old female enrollee has requested for a positron emission tomography (PET) scan for evaluation of her ovarian cancer.  Findings:  Three physician reviewers found that the National Oncologic PET Registry (NOPR) reports a 36.5% change in clinical management based upon PET imaging when all tumors are considered. In addition, the NOPR has petitioned the Centers for Medicare and Medicaid (CMS) for approval of PET imaging in all primary tumors as initial staging as well as for treatment monitoring. In the case of this patient, even though conventional imaging and CA-125 levels are unimpressive at the present time, she has documented previous widespread abdominal disease, and thus, is an appropriate candidate for restaging with PET prior to repeat surgery.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee requested Rituxan for treatment of her medical condition.  Findings:  Two physician reviewers found that there is a lack of support for the requested medication in this clinical setting.  Per the medical records, this patient has been diagnosed with peripheral nerve vasculitis (mononeuritis multiplex).  She has not responded to a trial of standard therapy medications.  The medical literature does not support treatment with Rituxan in this patients case.  Rituxan has not been proven to be safe and effective for the treatment of peripheral nerve vasculitis, mononeuritis multiplex.  There are other therapies with established efficacy available in this setting.  Therefore, Rituxan is not likely to be more effective than other treatment options. Final Result: Two 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: Reviewers 1, 2, and 3 are board certified in internal medicine with sub-specialty certification in rheumatology 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 breast tomosynthesis for evaluation of her medical condition.   Findings:  Three physician reviewers found that  peer reviewed literature supports the use of tomosynthesis in this clinical setting. Per Skaane and colleagues, the use of mammography plus tomosynthesis in a screening environment resulted in a significantly higher cancer detection rate and enabled the detection of more invasive cancers. Ciatto and colleagues state that integrated two dimensional and three dimensional mammography improves breast cancer detection and has the potential to reduce false positive recalls. For these reasons, tomosynthesis was likely to be more beneficial than any available standard therapy.  Final Result: Three reviewers determined that the service 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 overturned.  Credentials/Qualifications:  All three reviewers are board certified in diagnostic radiology and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 50-year-old female enrollee has requested authorization and coverage for Provigil and Marinol.  Findings:  The physician reviewer found that this patient has MS, which has reportedly been accompanied by neuropathic pain and fatigue. Central neuropathic pain has been reported to be among the most common pain syndromes in MS. Fatigue is also a common and disabling feature of MS. There is evidence in the medical literature that Provigil can be of benefit in the off-label treatment of fatigue in conditions such as MS and Parkinsons disease. In addition, literature studies regarding the use of Marinol for neuropathic pain demonstrate the utility of this medication in reducing nerve pain when compared to placebo. Thus, the use of Provigil and Marinol are appropriate for treatment of the patients medical condition, as their efficacy in the treatment of MS has been adequately demonstrated in the peer-reviewed medical literature.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: parent of the enrollee has requested reimbursement and prospective authorization and coverage for intensive outpatient program (IOP) services provided. Findings:  The physician reviewer found that based on the IOP records submitted for review, the patient has met the majority of the treatment goals. The remaining goals appear to be due to the patient's anxiety with transitions, rigid behaviors, following instruction, and listening to directions. These target behaviors are typical treatment goals of children with autism. In this clinical setting, the patients remaining goals can be appropriately treated with ABA. According to Myers and colleagues ABA methods are used to increase and maintain desirable adaptive behaviors, reduce interfering maladaptive behaviors or narrow the conditions under which they occur, teach new skills, and generalize behaviors to new environments or situations. In addition, the patient is not having any current suicidal or homicidal ideation. The patient continues to have behavioral struggles at home as well as aggressive episodes with a sibling. The progress notes do not indicate that the patient is aggressive with children at school. It appears that the patient's aggression is isolated towards a sibling. The patient is also noted to struggle with anxiety. The peer-reviewed literature indicates that cognitive behavioral therapy based interventions are effective in reducing anxiety symptoms in individuals with autism. Cognitive behavioral therapy is routinely provided on an outpatient basis. Per the Child and Adolescent Level of Care Utilization System (CALOCUS), the patient has a score of 14, which correlates with a treatment intensity level of two which correlates with outpatient services. The patient has some episodic outbursts, and is not having active suicidal ideation. The patients functional status is mild, has no co-morbidities and has a stable housing situation. Moreover, the patient has a highly supportive family who is actively involved in treatment and attend family therapy sessions on a regular basis. In sum, the patient has stabilized and current behavioral issues are secondary to the chronic nature of the patient's autism and can be treated on an outpatient basis.  The patient is not suffering from symptoms that would warrant the intensity of an IOP. Final Result: The reviewer determined that the services at issue were not and are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: physician reviewer is board certified in psychiatry with sub-specialty certification in child and adolescent psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 17-year-old male enrollee has requested corticosteroid injections for the treatment of the enrollees scarring. Findings:  The physician reviewer found that the clinical information demonstrates the proposed intralesional corticosteroid injections are medically necessary. The requested treatment is in accordance with accepted medical practice. It is clinically appropriate to decrease this patients hypertrophic scarring. The requested treatment is not being performed solely for convenience or cosmetic purposes, as it is being done to treat an injury.
Appeal type: Experimental/Investigational
Decision: Upheld

A 56-year-old female enrollee has requested reimbursement continued intravenous Rocephin therapy for the treatment of her Lyme disease. Findings:  Three physician reviewers found that the published data does not support treatment of patients until the IgM titer converts to negative. Titers may remain positive indefinitely and are not necessarily markers of disease activity. Further, there is no evidence of harbored Lyme infection with recrudescence over time. The Infectious Disease Society of America (IDSA) guidelines, though under review, are the most complete evidence-based medicine for the treatment of Lyme disease. The therapy at issue was not and is not more beneficial over the standard treatment of one four-week course of antibiotic for the treatment of late-stage Lyme disease. The therapy at issue was not and is not supported in peer-reviewed literature.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for magnetic resonance imaging. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services. Per the records, the patient has no history of trauma, malignancy or abnormal neurological examination to provide an indication for MRI of the lumbar spine at this time. There are no red flags to warrant MRI of the lumbar spine prior to a conservative trial of therapy, including physical therapy for six weeks, prior to advance imaging.  The current medical evidence does not support the requested services in this clinical setting. All told, the requested MRI is not medically necessary for the evaluation of this patient.  Final Result: The reviewer determined that the requested services are not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in diagnostic radiology 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 47-year-old female enrollee requested authorization and coverage of a laminectomy. The Health Plan denied the request indicating that the requested procedure is not medically necessary for treatment of the enrollee's back pain.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plans denial on the basis that the requested procedure is medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential care facility services from 11/10/15 through 1/13/16.Findings:  The physician reviewer found that residential treatment is considered the highest level of psychiatric care available.  Medical necessity guidelines and evidence-based practice indicate that psychiatric symptoms must be severe and present to the degree that this level of care is needed. While this patient did have some cutting behaviors during the disputed period (11/10/15 through 1/13/16), the progress notes indicate that she was cooperative in treatment and open to therapy. The patient did not express suicidal ideation or severe mood lability during the disputed period. Since the patient was cooperative in treatment, a less restrictive setting was appropriate for treatment during the disputed period. The functional impairment that the patient was struggling with may have been due to the patients borderline personality disorder.  One of the mainstays of treatment for borderline personality disorder is dialectical behavior therapy (DBT). This disorder can be treated in a less restrictive setting once patients are free from safety concerns, as indicated in this patients case.  A study notes, Dialectical behavior therapy appears to be uniquely effective in reducing suicide attempts. DBT is effective for the treatment of borderline personality disorder and is used on an outpatient basis on a regular basis. 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 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 37-year-old female enrollee has requested for acupuncture for treatment of her low back pain.  Findings:  The physician reviewer found that MRI confirms degenerative disc disease, and thus far, treatment with multiple modalities has not provided relieve. Acupuncture is a readily accepted treatment for musculo-skeletal symptoms and the record indicates the patients previous experience yielded positive results. A trial of acupuncture is clinically appropriate at this time. A reasonable trial would include up to 10 treatments over two months. If treatment is successful, authorization for additional sessions should be considered on an as-needed basis.