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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential treatment center services. Findings:  The physician reviewer found that the physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue. During the dates of service in dispute, the records indicate that the patient had stabilized and was eating appropriately. Her medical status was intact, and she appeared psychiatrically stable. She was not exhibiting severe mood, anxiety or psychotic symptoms and was not engaging in self-harm type behaviors. The progress notes indicated that the patient had cognitive issues. Throughout her stay, it did not appear that these cognitive issues improved, and it appears that she may have been at her baseline level of cognitive function. Further residential care would not be expected to improve these cognitive issues. As noted in the psychological evaluation, it was likely that the patient would need continued assistance after residential treatment was completed. It appears that she had reached maximum benefit from her residential stay. The progress notes indicated the patient went on passes with family members, and there was no indication of difficulties on these passes for any severe behavioral issues. The records indicated that the patient could have been treated safely and effectively in a less restrictive setting during the dates of service in dispute. The medical literature indicates that outpatient treatment with modalities such as cognitive behavioral therapy can be effective for treatment of anorexia nervosa. The residential treatment center progress notes indicate that the patient was cooperative in treatment, and the records demonstrate that less restrictive treatment would have been appropriate. All told, residential treatment center services were not medically necessary for the treatment of 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 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: An enrollee has requested authorization and coverage for Promacta 25 mg. Promacta for ITP is U.S. Food and Drug Administration (FDA) approved for the treatment of thrombocytopenia in patients with chronic ITP who have had insufficient response to corticosteroids, immunoglobulins, or splenectomy. The goal of ITP treatment is to provide a safe platelet count in order to prevent clinically significant bleeding. This patient may have secondary ITP, for which treatment of the underlying cause with rituximab or another agent may be indicated. All told, the records do not support the medical necessity of the requested Promacta 25 mg for treatment of this patients ITP. 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 sub-specialty certifications in medical oncology and hematology 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 authorization and coverage for gene panel testing (CPT 81405), (CPT 81479), (CPT81404), (CPT 81323), (CPT 81402), (CPT 81321), and (CPT 81406). Findings:  The physician reviewer found that routine genetic screening is not recommended for all inflammatory bowel disease (IBD) patients, although it should be considered depending on the age of onset and further criteria such as family history, relevant comorbidities, and extraintestinal manifestations. Genomic testing may be especially useful in children with very early-onset (VEO) IBD diagnosed under the age of two. The older the age of disease onset, the less likely a monogenic disorder is to be identified. Other factors which might lead one to test for monogenic disorder include relevant comorbidities suggestive of more generalized immunologic dysfunction, such as frequent or unusual infections. In this case, notes report that the patient was diagnosed with ileocolonic inflammatory Crohns disease. The records noted that the patients brother had a diagnosis of VEO-IBD. The records did not include documentation of specific concerns for an immunologic disorder, or if the patients brother has undergone genomic testing, and if so, any findings. At this point, the requested service appears unlikely to be helpful in providing a more precise diagnosis or targeted management of this patients early-onset IBD. Therefore, gene panel testing (CPT 81405), (CPT 81479), (CPT81404), (CPT 81323), (CPT 81402), (CPT 81321), and (CPT 81406) is not likely to be more beneficial for evaluation of the patients condition than any available standard therapy.Findings:  Two of the three physician reviewers found the requested gene panel testing (CPT 81405), (CPT 81479), (CPT81404), (CPT 81323), (CPT 81402), (CPT 81321), and (CPT 81406) 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 service 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 reviewers 1 and 3 are board certified in internal medicine with sub-specialty certification in gastroenterology and are actively practicing. Physician reviewer 2 is board certified in pediatrics with sub-specialty certification in pediatric gastroenterology 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

Nature of Statutory Criteria/Case Summary:   An enrollee has requested a sacral laminectomy, spinal dorsa graft and osteoplastic reconstruction of dorsal spinal elements following a primary intraspinal procedure of her lower back.   Findings:  The physician reviewer found that there is evidence based medical peer-reviewed literature that supports the use of microsurgical resection of Tarlov cysts as safe and effective treatment for symptomatic Tarlov cysts. Studies indicate that symptomatic Tarlov cysts are extremely rare. Burke and colleagues completed one of the largest published studies on patients with Tarlov cysts who were treated microsurgically. They studied 23 adults who were treated with laminectomy, microsurgical exposure and/or imbrication, and para-spinous muscle flap closure. The data suggested that patients with symptomatic Tarlov cysts may benefit from open microsurgical treatment. Although outcomes seem related to patient age, duration of symptoms, and extent of disease demonstrated on imaging, further study was warranted and reported underway. Another study reviewed by Xu and colleagues documented the outcomes of 15 patients with symptomatic sacral perineural cysts who were managed by three different modalities. Six patients underwent microsurgical cyst fenestration and cyst wall imbrication. Seven patients underwent a modified surgical procedure, during which the cerebrospinal fluid leak aperture was located and repaired. Two patients were treated with medication and physical therapy. They concluded that microsurgical operation should be a treatment consideration in patients with symptomatic sacral perineural cysts. Furthermore, the surgical procedure with partial cyst removal and aperture repair for prevention of cerebrospinal fluid leakage seemed to be more simple and effective. This patient presents with persistent pain and progressive neurological dysfunction attributable to the Tarlov cysts, and unrelated to her fibromyalgia. The submitted clinical exam findings and signs/symptoms are consistent with imaging evidence of very large Tarlov cysts arising from the S2 and possibly S3 nerve roots, and corroborated by electrodiagnostic findings of a lack of sural nerve response. Moreover, reasonable conservative treatment has been tried and has failed. Given the progressive neurologic dysfunction, the requested surgical intervention is medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the requested procedure 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 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: Experimental/Investigational
Decision: Overturned

A 58-year-old male enrollee requested Harvoni for medical treatment of his hepatitis C.  Findings:  Three physician reviewers found that in this patients case, Harvoni is likely to be of greater benefit than other treatment alternatives.  The proposed treatment is appropriate for this patients hepatitis C.  The use of this medication is likely to result in eradication of this virus and prevention of further progression of liver disease and its complications.  The current medical evidence supports Harvoni in this clinical setting.  Harvoni has been approved for the treatment of chronic hepatitis C, genotype 1 in both treatment-naive and treatment-experienced patients regardless of the fibrosis stage of the liver disease.  Therefore, the requested medication is likely to be more effective than other treatment options.
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 there is sufficient support in the peer-reviewed literature for the services at issue in this clinical setting.  Skaane and colleagues performed a large prospective screening trial To assess cancer detection rates, false-positive rates before arbitration, positive predictive values for women recalled after arbitration, and the type of cancers detected with use of digital mammography alone and combined with tomosynthesis.  The authors concluded that 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. Thus, the use of breast tomosynthesis was likely to be more beneficial for evaluation of the patients breast exam than conventional mammogram is due to improved cancer detection rate.  Final Result:  Three 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: 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: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested nasal endoscopic surgery for treatment of the enrollees sinusitis.  The physician reviewer found that while sinus ostial dilation may be an appropriate therapeutic option for patients with chronic sinusitis, the criteria have not been met in this patient. The indication for sinus surgery is chronic sinusitis refractory to maximal medical treatment. The American Academy of Otolaryngology Head and Neck Surgery (AAOHNS) defines chronic rhinosinusitis as a clinical disorder characterized by inflammation of the mucosa of the nose and paranasal sinuses with associated signs and symptoms of 12 week consecutive duration. In addition, the guidelines noted that chronic rhinosinusitis is characterized by two or more symptoms, one of which is nasal blockage/obstruction/congestion or nasal discharge (anterior/posterior nasal drip), with or without facial pain/pressure and reduction or loss of smell with endoscopic evidence of mucopurulence, edema, and/or polyps and/or CT presence of mucosal thickening or air fluid levels in the sinuses. Chronic rhinosinusitis has not been documented in this patient. There was no documentation of the chronology of her disease and there is a lack of radiographic evidence supporting the diagnosis of chronic sinusitis warranting sinus surgery. Therefore, the requested nasal endoscopic surgery is not medically necessary in this patient. Final Result: The reviewer determined that the requested surgery 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 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: Experimental/Investigational
Decision: Upheld

A 51-year-old female enrollee has requested breast magnetic resonance imaging (MRI) for evaluation of her history of breast cancer.  Findings:  Two physician reviewers found that in this patients case, the requested services are not likely to be more effective than other available treatment options. Although women with a previous diagnosis of breast cancer are at an increased risk for a second diagnosis, an American Cancer Society panel concluded that the increased risk due to a personal history of breast cancer alone does not justify a recommendation for overall screening with MRI in women who have undergone breast conservation therapy. Moreover, the American College of Radiology (ACR) has established guidelines for the appropriate use of breast MRI. The ACR practice guidelines state that MRI may be useful in women with a history of breast cancer and suspicion of recurrence when clinical, mammographic or sonographic findings are inconclusive. In this patients case, her mammogram on the said date was negative as there was no evidence of malignancy. For the reasons provided above, the requested diagnostic procedure is not more likely to be beneficial for evaluation of the patients medical condition than any standard therapy.
Appeal type: Medical Necessity
Decision: Overturned

The enrollee is requesting authorization and coverage for Otezla 30mg tablets. The enrollee has scalp psoriasis. A progress note showed the psoriasis had spread to her face and the provider ordered Otezla. An evaluation by the provider showed the scalp was itchy, inflamed and scaling. The enrollee also demonstrated a rash on the chin and both cheeks. The medication was found medically necessary because other treatment options are not medically appropriate for this patient. Firstly, ultraviolet B phototherapy can't reach the scalp and this is not practical. Secondly, this enrollee is of child-bearing age, and drugs that can cause potential birth defects such as methotrexate, cyclosporine or Soriatane should be avoided. Additionally, methotrexate and cyclosporine cause immune suppression, which can dramatically increase an otherwise healthy individuals risk of contracting a viral infection. This enrollee has a history of hair loss and Soriatane can cause hair loss. Thirdly, the enrollee has already started Otezla and it cleared her condition. This condition flared when the Otezla was discontinued. Lastly, Otezla is a safe drug and does not need any additional monitoring. Final Result: The reviewer determined that the requested service is medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in dermatology 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 62-year-old male enrollee requested authorization and coverage of the medication Sporanox for the treatment of toenail fungus.  The health plan denied the enrollees request indicating that the requested medication 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 medication is not medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld

A 53-year-old female enrollee has requested compounded progesterone powder with compounded Tri-Est for treatment of her postmenopausal.  Findings:  Three physician reviewers found that Tri-Est is a combination of estriol, estradiol and estrone. In 2008, the Food and Drug Administration (FDA) stated that estriol is not a component of an FDA-approved drug and has not been proven safe and effective for any use. The FDA has noted concerns regarding the safety and efficacy of compounded bioidentical hormones. The FDA noted that compounded drugs are not reviewed by the FDA for safety and effectiveness.   The American Congress of Obstetrics and Gynecology (ACOG) has also weighed in on this topic. In 2009, ACOG reiterated its position that there is a lack of scientific evidence supporting the safety or efficacy of compounded bioidentical hormones.  ACOG noted that bioidentical hormones have not undergone rigorous testing for safety or efficacy, and hormone therapy does not require customized dosing.  Thus, at this time, the current medical evidence has not demonstrated that bioidentical hormones are more efficacious than other treatment options.  In this patients case, the superior efficacy of the requested compounded progesterone powder with compounded Tri-Est has not been established.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The overarching goal of home health care is to optimize each childs health and function while minimizing recurrent or prolonged hospitalizations through the provision of comprehensive, family-centered health care rendered in a nurturing home environment. In the current era, alternative models of service delivery such as homebased nursing services have become more important, and also as it has become more feasible to provide hightechnology interventions at home. Accepted indications for private duty nursing often include the administration of medications, monitoring oxygen saturations, and enteral feeding, all of which are required in this case. According to this patients home nursing health plan, skilled nursing services were indicated to conduct the following: monitor vital signs; perform nursing assessment; provide G-tube care; implement seizure precautions; monitor lungs sounds; perform oral suctioning; assist with range of motion; and monitor for skin breakdown. While her parents are nurses and may be able to meet the ongoing needs of their child in the short-term, this is not sustainable for long-term care. According to researchers, 54% of families caring for a child with special needs reported that a family member stopped working because of the childs health, with more than 20% of families reporting financial problems attributed to their childs condition. Given these findings, the private duty nursing services provided were medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the requested services were 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 pediatrics with subspecialty certifications in neurodevelopmental behavioral pediatrics and genetics 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

The parent of an 8-year-old male enrollee has requested one-on-one occupational therapy (OT) (3 times per week); and for make-up occupational therapy sessions to be scheduled for treatment of the enrollees autism spectrum disorder. Findings:  The physician reviewer found that according to Weinman and colleagues, successful OT should permanently improve the childs motor and self-skills as the child matures. In this case, based on the documentation submitted for review this patient has made limited progress in the reported OT sessions. Despite OT services at the frequency of 3 hours per week , an assessment indicated serious and multiple difficulties in self-help skills. In addition, the patients treating occupational therapist stated on the date indicated that 1 hour of OT is sufficient for the patient. Although the patients parent reports his regression since OT sessions were reduced from 3 hours per week to 1 hour per week, acquired OT skills should be fixed and permanent in patients who are responsive to OT. Finally, the number of goals recommended in the  assessment is excessive given the patients prior experience and limited improvement from extensive OT. In this case, the patients goals should be limited to an achievable number of goals. As such, one hour of OT per week as authorized by the Health Plan is adequate and medically reasonable. Moreover, increasing OT hours through make-up sessions is not medically indicated. Therefore, based on the medical literature cited above and the documentation submitted for review, the requested services are not medically necessary for treatment of the patients medical condition.