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

A 49-year-old female enrollee requested dextroamphetamine for medical treatment of the enrollees fatigue.  Findings:  The physician reviewer found that the current medical evidence does not support the requested medication in this clinical setting.  Dextroamphetamine may be indicated for the treatment of narcolepsy and attention deficit/hyperactivity disorder.  However, there is a high potential for abuse when using amphetamines, and prolonged use should be avoided.  There is no indication to use dextroamphetamine to treat the sedating side effects of opioid analgesic medications.  There is no supporting documentation indicating that the patient has been diagnosed with narcolepsy or chronic fatigue syndrome.  All told, dextroamphetamine is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 16-year-old male enrollee has requested residential for treatment of the enrollees behavioral health condition.  Findings:  The physician reviewer found this patient has an element of chronicity based in part on his stunted ability to self soothe and delay gratification combined with other biological, psychological and characterological influences. Considering the formidability of the symptom complex, clinical recommendations and past treatment history, it was reasonable to expect that the residential placement would improve his situation and prevent a more serious condition.  The residential treatment services were a safe and appropriate disposition consistent with good practice. However, it became evident that the patient was progressing towards discharge. He had improved on his medications.  He was responding to redirection. He was less invested in the setting and desiring to return to home. This phase shift is quite important as a sound treatment foundation and therapeutic momentum can be generated in a residential setting, but enduring treatment gains are optimized in community settings. In the absence of any additional documentation, the patient was suitable for transition to a less-restrictive treatment setting.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for acupuncture treatments for treatment of the enrollees fatigue, insomnia, nausea and vertigo. Findings:  The physician reviewer found that acupuncture has been shown to be effective for the management of pain and fatigue related to illness. Acupuncture has demonstrated benefit across a variety of conditions including chronic pain. Peer-reviewed publications provide support for acupuncture in treating anxiety, sleep disturbances, depression and chronic pain. Acupuncture relieves pain better than sham acupuncture, as measured at completion of treatment and at short-term follow-up. The medical records document that this patient has been treated with acupuncture with reported good response and functional gain. All told, the acupuncture treatments were and are medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the services at issue were and 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 neurology with sub-specialty certification in pain medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested AlloMap gene expression profiling for evaluation of his medical condition. Findings: Three physician reviewers found that AlloMap was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. AlloMap gene expression profiling has been widely accepted and deployed by the majority of cardiac transplant centers in the United States. The use of this study limits the need for invasive endomyocardial biopsy (EMB) with its attendant risks in stable patient with no signs of rejection. The study is used in the first year post-transplant and has support in the peer-reviewed literature. Moreover, AlloMap has become the standard of care for managing stable post-transplant patients. For all of the above reasons, the AlloMap testing was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.  Final Result: Three reviewers determined that the services at issue were and are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial has been overturned.Credentials/Qualifications: All three reviewers are board certified in internal medicine with sub-specialty certification in cardiovascular disease and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for gene panel testing. Findings:  Three physician reviewers found there is sufficient support for a portion of the services at issue. The American College of Obstetricians and Gynecologists recommends that providers offer screening for spinal muscular atrophy to all patients who are considering pregnancy or who are currently pregnant. The records document that this patient underwent screening for spinal muscular atrophy. Thus, the medical evidence supports this testing in this clinical setting. However, the submitted documentation indicates that CPT code 81401 is in dispute. This code represents a complete gene panel. The records did not provide further support for the remaining of the tests which were included in the gene panel testing. In sum, screening for spinal muscular atrophy was likely to have been of greater benefit than other methods of evaluating this patient. However, the superior efficacy of the remaining tests of the gene panel testing has not been established.Final Result: The 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 reviewers 1, 2 and 3 are board certified in obstetrics and gynecology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

A 55-year-old male enrollee requested authorization and coverage of gastric bypass with duodenal switch. The Health Plan denied the request indicating that the requested procedure is considered experimental for treatment of the enrollees morbid obesity.Three physician reviewers performed an experimental/investigational Independent Medical Review. Two physician reviewers concluded that the requested procedure is likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy. One physician reviewer concluded that the requested procedure is not likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy. Because two of the three physician reviewers concluded that the requested procedure is likely to be more beneficial for the treatment of the enrollee's medical condition than any available standard therapy, the Health Plans denial has been overturned.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: an enrollee has requested authorization and coverage for Harvoni 90 mg-400 mg tablets. Findings:  The physician reviewer found that according to the recent joint guidelines issued by the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America (AASLD), all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. This applies regardless of fibrosis stage or viral load, and advanced fibrosis is not required for treatment. For treatment naive patients with hepatitis C, genotype 6 infection, the guidelines recommend Harvoni for 12 weeks. This is based on both in vitro data and clinical trial results showing 96% sustained virologic response after 12 weeks of therapy. AASLD guidelines cite data showing reduced survival with delayed treatment. For these reasons, Harvoni 90 mg - 400 mg tablets is supported as medically necessary for the treatment of this patients hepatitis C infection. Final Result: The reviewer determined that the requested medication regimen 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 with sub-specialty 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: Experimental/Investigational
Decision: Overturned

The parent of a ten-year-old male enrollee has requested ankle foot orthotics (type R-Wrap) for the treatment of the enrollees cerebral palsy, spastic quadriplegia. Findings:  Two physician reviewers found that R-Wrap ankle foot orthotics would be superior for treatment of this particular patient as traditional ankle foot orthotics do not maintain his feet in neutral position, and he is also having mid-foot breakdowns. This patient fits the criteria for this brace and has not had significant success with other traditional ankle foot orthotics. With the R-Wrap brace, he has potential to improve functional mobility with more comfort and less skin breakdowns.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 5-year-old male enrollee has requested for occupational therapy for treatment of his fine motor delay. Findings:  The physician reviewer found that with its focus on developing motor planning skills, teaching self-help skills, and developing fine and gross motor skills, occupational therapy is well-suited to affect positive change in this child. Occupational therapy is therefore medically necessary and appropriate for the full duration in question (6 months).
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested proton beam radiation therapy and full body positron emission tomography/computed tomography (PET/CT) using choline C-11 for treatment of his medical condition.  Findings:  Three physician reviewers found that the submitted documentation fails to demonstrate the superior efficacy of the requested services.  The standard treatment for patients who have a rising PSA following radiation therapy is with hormone therapy or chemotherapy. In patients requiring palliative radiation to the spine for bone metastases, there is a lack of evidence to suggest that proton radiation therapy will improve outcomes. Standard radiation in patients with metastatic disease is with standard photon techniques.  Furthermore, there is a lack of medical literature to suggest that volume based radiation planning based on a C-11 choline PET/CT scan improves outcomes. Therefore, the requested services are not likely to be more efficacious for treatment of the patients medical condition than other treatment options. Final Result: Three reviewers determined that the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications:  All three reviewers are board certified in radiation oncology 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Guardant360 laboratory testing for evaluation of the enrollees non-small cell lung carcinoma. Findings:  The physician reviewer found that the National Comprehensive Cancer Network Guidelines for non-small lung cancer, version 1.2018 states that adequate tissue is needed for molecular testing. If there is not available tissue, plasma testing can be done such as Guardant360. In this case, there is adequate tissue as evidenced by the reading of the pathology report. BRAF, ALK, EGFR, MET, RET, ERBB2, PDL1, ROS-1 can be performed on tissue. In addition, PET/CT demonstrating stage IV disease was not provided. Molecular testing is not indicated in stage III disease. The medical literature does not support the superior efficacy of this testing in this clinical setting. Accordingly, Guardant360 laboratory testing was not likely to have been more effective than the available options of evaluating this patient. Final Result: The reviewers determined that the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Reviewer 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in medical oncology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 15-year-old female enrollee requested psychiatric residential treatment center (RTC) level of care services for treatment of the enrollees behavioral health condition.  Findings:  The physician reviewer found thatthe RTC services provided were and are medically necessary for treatment of the patients medical condition. Based on the documentation submitted for review, the patient is at moderate but stable risk of harm and needs medium-intensity 24-hour monitoring to ensure her safety. This is based upon her lacking a will to live and not being afraid of negative consequences. She also has moderate to severe interference with addiction recovery. Her history, combined with the present situation, predicts that she would likely destabilize without medium-intensity residential treatment. In addition, the patient needs intensive motivating strategies in a 24-hour structured program to address minimal treatment engagement. She is also unable to control use and avoid serious impairments without a 24-hour structured program because she is unable to overcome environmental triggers. Finally, the patients home environment poses a risk to her recovery, based upon the amount of dysfunction that is present due to the lack of unity between parents. Based on the medical literature cited above and the documentation submitted for review, the services at issue were and are medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement and authorization and coverage for wilderness therapy.Findings:  Two of three physician reviewers found that the current medical literature supports the use of wilderness therapy in this clinical setting. Behrens and colleagues noted that a longitudinal outcome study of wilderness therapy programs has shown that youth in the study experienced significant decreases in suicidal ideation, anxiety, depression, substance abuse, social conflict, sleep disruption, violence, as well as an overall reduction in externalizing behaviors such as impulsivity, defiance, and hostility. Furthermore, these youth demonstrated improvements in work and academic functioning during the follow-up portion of the study. Hoag and colleagues conducted a pilot study that investigated the effectiveness of wilderness therapy for 297 young adult participants. Their 3-year study found statistically significant changes on measures of life effectiveness, motivation for therapy, therapeutic alliance, and dysfunctional attitudes. Magle-Haberek and colleagues have also conducted research which showed that residential treatment center programs were not more effective than outdoor behavioral healthcare, or wilderness programs, in predicting change. In this case, the patient has failed inpatient and residential treatment center treatment, and the patients illness is severe. Wilderness therapy, as noted in the medical literature, is also clinically appropriate for the patient's illness. Accordingly, wilderness therapy was and is likely to be more beneficial than any other available standard therapy for the patients medical condition.Final Result: Two of three reviewers determined that the services at issue and requested services were and are likely to be more beneficial than any other available standard therapy for the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: Physician reviewer 1 is board certified in psychiatry, with subspecialty certification in child and adolescent psychiatry, and is actively practicing. Physician reviewers 2 and 3 are board certified in psychiatry and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: A transgender enrollee has requested reimbursement for breast augmentation for treatment of the enrollees gender dysphoria. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity for the procedure at issue. The patient underwent sex reassignment surgery with bilateral augmentation mammaplasty.  The patient is well-documented to have gender dysphoria. Thus, her external anatomy should be more consistent with a female than a male. However, a detailed preoperative breast examination was not documented by the surgeon prior to the surgery. In addition, preoperative photographs were not provided to assist in determining the degree of breast development that the patient had following her hormonal therapy. The surgeon states that the patient had very little breast development consistent with Tanner Stage 2. However, there was no documentation supporting this statement prior to her surgery. There is no documentation of preoperative anatomic measurements and no other breast examination details have been provided.  All told, there is insufficient preoperative documentation to adequately characterize the patients breast development. Therefore, the medical necessity of breast augmentation surgery for treatment of the patients gender dysphoria has not been established. In sum, the breast augmentation surgery was not medically necessary for the treatment of this patients gender dysphoria. With regard to whether the procedure at issue is considered reconstructive in nature, there is insufficient clinical documentation to determine if the patients breast development was abnormal for a female. Preoperative photographs and a detailed preoperative breast examination have not been provided. Final Result: The reviewer determined that the procedure at issue was not medically necessary for treatment of the patients medical condition and was not reconstructive in nature. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in plastic 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

A 44-year-old female enrollee has requested continued physical therapy for treatment of her thoracic outlet syndrome and cervicalgia. Findings:  The physician reviewer found that the goals for this patient included further reduction in pain with various activities, increased upper extremity strength and increased cervical range of motion. Therapy notes document that the patient is responding well to physical therapy at an appropriate pace of recovery. Specific goals justifying additional therapy have been established, and these goals should be achievable in a reasonable and predictable period of time. Physical therapy is an effective treatment for cervicalgia, as noted by Hoving and colleagues. It is also the initial treatment of choice for thoracic outlet syndrome. Continued physical therapy is medically indicated for this patient.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for Xifaxan.Scarpellini and colleagues state that Xifaxan has proven highly effective in small intestinal bacterial overgrowth for eradication of bacteria and symptom relief. In a study by Scarpellini and colleagues, bacterial overgrowth eradication was demonstrated in 80% of patients taking Xifaxan versus 54% for patients taking a placebo. Additionally, the medication has greater effectiveness with fewer side effects than antibiotic alternatives such as metronidazole, neomycin, and fluoroquinolones, according to Lauritano and colleagues. Results are sustained for several weeks after treatment. More recent studies have corroborated these findings, including in patients with a positive breath test for SIBO. In this case, the patient has SIBO documented with testing, and has persistent associated symptoms. For these reasons, the requested Xifaxan is medically necessary for the treatment of the patients medical condition.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 internal medicine with sub-specialty 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.