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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Evenity (romosozumab-aqqg) monthly injections (J3111). Per evidenced-based guidelines, intravenous (IV) bisphosphonate therapy is recommended for the treatment of osteoporosis to decrease osteoporotic fractures in patients who are intolerant to oral bisphosphonates. Evenity is another treatment option for postmenopausal women at high-risk for osteoporotic fracture. However, current studies have reported an increased risk of serious adverse cardiovascular events with Evenity when compared to IV bisphosphonate therapy. This patients records document osteoporosis with a T-score of -3.7 in the spine. The patient was reportedly treated with Fosamax, which was discontinued due to gastrointestinal distress. The provider has recommended Evenity in lieu of IV bisphosphonates to avoid reduced efficacy of other agents such as Prolia, Forteo, and Evenity. The records provided for review do not report the patients current cardiovascular history to establish the risk associated with use of Evenity. Moreover, there is no documentation of a trial of IV bisphosphonate therapy. All told, the requested Evenity (romosozumab-aqqg) monthly injections (J3111) are not medically necessary for 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 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: Medical Necessity
Decision: Overturned

The patient is an 18-year-old male with previously diagnosed major depression, recurrent as well as social and school phobia, which first became notable at age 7 and persisted to age 12. Some of his school and social phobia improved with the help of an antidepressant, whereupon it was discontinued by the sixth grade. However, the patient was noted to have a persistent lack of motivation and by his junior year of high school he had been at a total of eight schools. Thereafter, his depression became more severe, accompanied by lying about homework, being rude and defiant with authority, losing fifteen pounds, and needing to be hospitalized for depression and suicidal ideation. The first hospitalization occurred in January 2003. The patient had dropped out of high school though did obtain a GED. The patients depression has been described as attendant with low energy, lack of motivation, erratic sleep, moderate anhedonia, intermittent hopelessness, and suicidal feelings though no set plans for the latter. Treatment with medications such as Wellbutrin, Risperdal, Effexor, Zoloft, Geodon, Trazodone, and Lexapro were felt to be ineffective.Treatment at the residential treatment facility involved both schooling itself as well as individual psychotherapy. During this time the patient was treated with Wellbutrin and Lexapro, though the latter was eventually tapered away entirely by the end of his stay. He was seen both by his therapist as well as his psychiatrist as likely suffering from dysthymia. However, more importantly, the patients dominant character pathology was mostly in the realm of narcissism. The patient more consistently appeared detached and haughty, with a nearly assumed identity of the chronically depressed, almost as a means of self-promotion. Review of therapy summary notes shows the patient as having made progress during his treatment such that he was not quite as reflexively focused on feeling depressed and was seen as a bit more interpersonally proximate. As well, it is reported he scored an 800 on his verbal SAT and was now able to consider entering a university.Given the decline of this patients function over prior years, attendant with deepening of his depression, residential treatment was medically indicated. Though he was ultimately seen as not nearly as depressed as characterologically disordered, the latter is not only no less relevant but likely more enduring a problem for him. As such, a sustained therapy program such as the one provided at the residential treatment facility was greatly needed. In point of fact, the patients condition appears to have improved substantially as a result of treatment. He has achieved greater interpersonal proximity with less externalization of his difficulties. It is unlikely that the patient would have achieved such results at a lower level of care. Therefore, I have determined that the services at issue were medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential treatment services for treatment of her behavioral health condition. Findings:  The physician reviewer found that in most clinical settings, the least restrictive level of care is preferred. In this patients case, continuation of relapse prevention education and treatment did not require the structure of the residential setting. The submitted documentation demonstrates the patient showed mild post-acute withdrawals.  She had a Clinical Institute Withdrawal Assessment (CIWA) score of 7, and showed mild tremor, sweats, anxiety, and headache.  The records noted that she was highly motivated, and availed herself of all groups, individual, and family treatments. She was noted as compliant.  Her mood was depressed and anxious. Her affect was for the most part flat, with occasional lability.  She planned to go to sober living, as she was aware that her husband triggered her.  The documentation noted that she was alert and oriented in all spheres. She was not a danger to herself or others, and she was medically and psychiatrically stable.  In addition, there were no emotional, behavioral, cognitive, impulsive, or manic factors, which would preclude recovery at a lower level of care.  Further, she was highly motivated and engaged in treatment.  Moreover, she had no recent substance abuse treatment, and there was no evidence that she would have relapsed if treatment were rendered at a lower level of care.  She was working on issues of anxiety, self-esteem/self-worth, and perfectionism in individual therapy.  The records demonstrate that this patient could have received treatment at a lower level of care. 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 sub-specialty certification in addiction 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 59-year-old female enrollee requested authorization and coverage of an electric wheelchair for treatment of status post cerebral vascular accident (CVA) with left hemiparesis.  The health plan denied the enrollees request indicating the Electric wheelchair is not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer overturned the health plans denial on the basis that the requested electric wheelchair is medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

The patient has requested reimbursement and prospective authorization and coverage for partial hospitalization program (PHP) services. The American Association of Community Psychiatrists Level of Care Utilization System (LOCUS) provides a reliable framework for determining the appropriate level of care for adults needing mental health treatment. Using LOCUS, providers 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. Applying the LOCUS framework, this patient met the criteria for PHP services already provided. These findings give the patient a composite score which is consistent with medically monitored community based services. Per LOCUS algorithm, reviews should not be required more often than every two weeks for acute care settings such as PHP. In this case, the patients history of serious disordered eating including multiple recent hospitalizations, and her continued struggles with body image and urges to exercise, support the PHP services already provided as medically necessary. However, based on the available documentation, the records do not support a current indication for PHP level of care services. Therefore, the PHP services were medically necessary for treatment of this patient, while the requested return to PHP level of care is not medically necessary for 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

This case involves a 14-year-old male with idiopathic short stature. It does not appear GH stimulation testing has been performed. A brain MRI revealed a normal appearing pituitary. Recent serum levels of IGF-1 were normal for Tanner stage 4 of sexual development at 341. The projected adult height was 65 inches compared to a mid-parental height of 70.5 inches. Based upon the submitted records, it appears that the patients growth has always been just below the 3rd percentile. The submitted materials indicated GH was prescribed in June 2005. The endocrinologist noted that the patient had not had a pubertal growth spurt. After GH therapy, the summary indicates a growth velocity of 11.7 cm per year. The patient has requested authorization and coverage for growth hormone therapy. The Health Plan has denied this request on the basis that the requested therapy is not medically necessary for treatment of the patients medical condition.The Food and Drug Administration (FDA) approved GH therapy for idiopathic short stature (ISS) defined by the following: height of under 2 standard deviations (1.2 percentile); height velocity unlikely to permit attainment of adult height in the normal range, if they had not yet closed their epiphyses; and diagnostic evaluation has excluded other causes associated with short stature. These percentiles extrapolate to adult heights of less than 53 for men and less than 411 for women. The pivotal randomized double blind study concerned 71 children aged 9-15 years of age given GH or placebo three times weekly until final adult height was reached. Of the 33 patients who contributed final adult height measurements after a mean duration of 4.4 years of treatment, the mean final height achieved by GH treatment was +1.5 inches over placebo treated controls. In the second study where treatment was in 3 different doses for a mean of 6.5 years, mean final height exceeded final height predicted at baseline by nearly 3 inches. Though it has been proven that adult height can be increased in children with idiopathic short stature as indicated in the information cited in the FDA application, the FDA has imposed restrictions to limit usage to those destined to be short adults. The height prediction involved in this case is above that target, and the height velocity and height for age also apparently fail to meet the FDA criteria. Thus, based upon the information provided, GH therapy is not medically warranted in this case. Therefore, I have determined the requested therapy is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Overturned

A 69-year-old male enrollee has requested an endoscopic Maze procedure for treatment of his atrial fibrillation.  Findings:  Two physician reviewers found that in the peer-reviewed medical literature and clinical practice, the endoscopic Maze, mini-Maze, or robotic Maze, are all recognized treatment options for patients with AF following failure of medical therapy and cardioversion procedures. The Maze procedure is less invasive than the Cox-Maze approach, and there are reliable data demonstrating positive outcomes with the Maze technique. As this patients provider has recommended the Maze instead of the Cox-Maze procedure, the requested services are likely to provide this patient with greater benefit than any standard alternative and should be approved.
Appeal type: Medical Necessity
Decision: Upheld

A 64-year-old female enrollee requested authorization and coverage of a virtual colonoscopy due to a very difficult sigmoidoscopy a year ago;  the enrollee could not tolerate a barium enema. 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 virtual colonoscopy is not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for proton beam radiation therapy. Proton radiation therapy has not been demonstrated to be superior to photon intensity modulated radiation therapy (IMRT) for the treatment of neurofibromatosis syndrome. There is a lack of data in the medical literature demonstrating that proton radiation therapy yields improved clinical outcomes for a patient with neurofibromas, as compared to a regimen of photon-based intensity modulated radiation therapy (IMRT). The American Society for Radiation Oncology (ASTRO) policy supports use of proton beam radiation therapy for patients with documented neurofibromatosis. This patients records do not document results of genetic testing demonstrating findings of neurofibromatosis. In this clinical setting, the standard of care remains IMRT. Accordingly, the proton beam radiation therapy was not and is not medically necessary for treatment of this patient.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: The reviewer is board certified in radiation 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: Medical Necessity
Decision: Upheld

A 47-year-old female enrollee has requested for treatment from a foot and ankle orthopedic specialist for treatment of her hammertoes and bunions. Findings:  The physician reviewer found that bunions and hammertoes are routine podiatric problems than can be safely and effectively treated by a podiatrist. Podiatry care for these complications is totally within the standard of good medical care.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for magnetic resonance imaging (MRI) of the left shoulder. This patient presents with complaints of left shoulder pain with paresthesias in her hands. Prior imaging of the left shoulder revealed calcific deposits in the rotator cuff. Although calcific tendinitis is a common shoulder disorder, it requires differentiation from dystrophic calcification in a chronic rotator cuff tear. These two conditions should be differentiated by obtaining an MRI scan of the shoulder as the pathogenesis and treatment for these two conditions is different. Although routine conventional x-rays demonstrated calcific deposits, an MRI scan is appropriate to evaluate any coexisting pathology. Therefore, the requested MRI of the left shoulder is medically necessary for evaluation of this patient.Final Result: The reviewer determined that the requested services are medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

This patient is a 50-year-old woman with painful arthritis involving her right and left knees. She has undergone arthroscopic procedures on both knees; the left in 2000 and the right in 2005. The patient has been treated with Synvisc injections in the past and found them to be beneficial. Her provider has requested authorization for a repeat series of bilateral Synvisc injections. The Health Plan denied the request based upon a determination that the therapy is not medically necessary.The patient is a relatively young woman with severe osteoarthritis who wishes to delay knee replacement. Her orthopedist reports significant relief with previous Synvisc injections and recommends an additional series at this time. Synvisc therapy is an appropriate intervention to alleviate pain and postpone surgical intervention and a repeat series of injections is a reasonable treatment option for this patient. Therefore, I have determined the requested therapy is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for gastric bypass surgery with laparoscopy in conjunction with hiatal hernia repair. This patient has longstanding history of morbid obesity and is status post lap band removal and conversion to sleeve. The records document that the patient has sustained complications of the sleeve procedure with worsening GERD and dysphagia which may be related to the residual gastric cardia and hiatal hernia. The patients pH monitoring was consistent with severe GERD. In specific clinical setting, the standard treatment for GERD secondary to sleeve gastrectomy complications is conversion to Roux-en-Y gastric bypass surgery. This patient lost pounds with the sleeve gastrectomy and remains morbidly obese. The patient has completed an updated multidisciplinary evaluation as recommended by the American Society of Metabolic and Bariatric Surgery guidelines for repeat bariatric surgery. Medical necessity of conversion to Roux-en-Y gastric bypass surgery and hiatal hernia repair for treatment of post sleeve gastrectomy GERD with persistent morbid obesity is therefore determined. Accordingly, the requested gastric bypass surgery with laparoscopy in conjunction with hiatal hernia repair are supported as medically necessary for treatment of this 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 surgery with sub-specialty certification in bariatric 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for FoundationOne testing for evaluation of the enrollees metastatic cholangiocarcinoma.Findings:  The 2 of the physician reviewers found that found there is sufficient support for the services at issue in this patients case. Metastatic cholangiocarcinoma is a rare cancer with a poor prognosis and few effective treatment options. According to the National Comprehensive Cancer Network guidelines, trials are ongoing to evaluate systemic therapies for emerging molecular targets in hepatobiliary cancers. For patients with advanced disease, providers may wish to consider molecular profiling to determine eligibility for clinical trials of new molecular targeted agents. In this patients case, FoundationOne testing was likely to have been superior over other methods of evaluating this patient. Final Result: The reviewers determined that the services at issue were 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: 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 50-year-old female enrollee has requested neurofeedback services for treatment of her bipolar disorder. Findings:  Three physician reviewers found that neurofeedback of the brain is considered investigational for all indications including treatment of depression and all other psychiatric disorders (i.e., mood disorders, anxiety disorders, and schizophrenia). There is no current recommendation in the practice guidelines supporting the use of this method for the treatment of post-traumatic stress-disorder (PTSD) or bipolar disorder. The American Psychiatric Association (APA) guidelines offer many treatment modalities including medical therapy, which has reportedly provided this patient substantial benefit in the past. Moreover, there are additional standard, proven therapeutic options for this patient. These available standard treatment modalities should be employed prior to utilizing neurofeedback, which has not been established as a safe and effective treatment for PTSD.