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

A 54-year-old female enrollee has requested Olysio in combination with Sovaldi for treatment of her hepatitis C. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication combination.  The treatment of hepatitis C is undergoing rapid evolution.  This patient is not a candidate for interferon-based therapy because of her multiple relapses.  The request for Olysio and Sovaldi is based on phase II data which is encouraging.  However, the patient has relatively minimal fibrosis and does not require immediate therapy.  In this patients case, the requested medication combination is not indicated at this time.  All told, Olysio in combination with Sovaldi is not medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

A female enrollee requested lab testing including serum adalimumab (Humira) levels and antibiotics to adalimumab for medical evaluation of her Crohns disease. Findings:  Two physician reviewers found that monitoring patients on adalimumab with measurement of levels and antibodies to adalimumab continues to be an area of intense investigation. In general, adalimumab levels correlate inversely with disease activity. The presence of antibodies may explain loss of response. However, use of the test is problematic since antibodies can be transient and may not be biologically significant in an individual patient. Moreover, the target level of adalimumab necessary to achieve clinical benefit remains unknown. Overall, there is a lack of randomized prospective trials demonstrating that treatment guided by trough adalimumab levels is superior to optimal clinical care. Thus, lab testing including serum adalimumab (Humira) was not likely to have been more beneficial for evaluation of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for partial hospitalization services and prospective authorization and coverage for partial hospitalization services for treatment of the enrollees behavioral health condition.Findings:  The physician reviewer found that the Level of Care Utilization System (LOCUS) criteria is an accepted, national standard for determining the appropriate level of care for adults. According to the LOCUS criteria, her risk of harm is scored a 3, moderate risk. The record does not indicate that the patient has attempted suicide. The patient does have intermittent suicidal ideation, but she did not have any current suicidal ideation. She has a history of superficially scratching herself. Her functional status is also a 3, moderate impairment. The patients eating disorder has caused impairment in her eating habits. It does not appear that the patient is employed and able to maintain a job. The patients medical/addictive/psychiatric comorbidity is scored a 3, which correlates to significant comorbidity. The patient has a significant comorbidity of anorexia nervosa restricting type, major depressive disorder, and social phobia. She has been medically stable and has no medical conditions that require frequent monitoring. Her eating disorder at times can be debilitating. Her recovery environment is scored a 2, mildly stressful environment. The patient recently came out as lesbian which the patient reports triggered body image issues. Under the LOCUS criteria, her level of support is a 2, supportive environment. The patient has supportive parents. Her treatment history is scored a 2 which correlates to significant response to treatment and recovery. The patient has had a good response to treatment. She is at 100% of her ideal body weight and has been compliant with treatment. Her engagement and recovery status is a 3, limited engagement and recovery. The patient is compliant with treatment, but will still restrict food when home alone. She still has some hesitation in accepting her illness. She has a limited confidence to change despite intensions to do so. Based on the LOCUS criteria, her total score is 18, which meets criteria for a less restrictive environment at an intensive outpatient program and not PHP.   Final Result: The reviewer determined that the services at issue were 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 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 16-year-old male enrollee has requested  mental health inpatient treatment and residential treatment care services for treatment of the enrollees mental health condition. Findings:  The physician reviewer found that in regards to the request for residential level of care, the American Academy of Child and Adolescent Psychiatrys practice parameter for depression states, Finally, 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. In this case, the patient has autistic spectrum disorder, which comprises highly recognizable developmental conditions firmly steeped in biological etiology and characterized by deficits in general sociability, such as relatedness and reciprocity that can persist across the life span. Additionally, the patient has a co-occurring mood disorder and a concerning history of behavioral indiscretions. He has demonstrated agitation and para-suicidality in the home. Despite previous treatment interventions, the patient has not consolidated the treatment gains necessary to succeed in the community setting. However, considering his affective stability and medication tolerability during the acute hospitalization, it is reasonable to expect that the residential setting will improve his condition and prevent a more serious episode of illness. Considering these variables, the patients clinical presentation and relevant peer-reviewed literature, residential treatment is safe, appropriate and consistent with good medical practice. Thus, residential treatment care from the date indicated forward was and is medically necessary to treat the patients mental health condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 50-year-old female enrollee has requested a contrast-enhanced computed tomography angiography (CTA) for an evaluation of her cardiac arrhythmia. Findings:  Two physician reviewers found that the patient has atypical chest discomfort, no documented cardiac risk factors, and a stress echo that showed no evidence of provocable ischemia at an adequate cardiac workload. In this circumstance, the post-test likelihood of significant coronary stenosis is negligibly low, such that additional cardiac testing for coronary stenosis is not warranted. The patient has no documented cardiac risk factors and no provocable ischemia on stress testing so her atypical chest discomfort is likely non-cardiac and related to her other conditions known to cause chest pain. Additionally, nationally endorsed appropriateness criteria for coronary CT angiography as discussed by Hendel and colleagues do not recommend using the test in this circumstance.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested inpatient behavioral health services for treatment of his behavioral health condition. Findings:  The physician reviewer found that although inpatient care was initially indicated, the medical record does not support the medical necessity of continued inpatient level of care.  The nursing notes indicated that the patient remained symptomatic, but not distressed.  Although the patient remained symptomatic, the record demonstrates that the acute psychiatric syndrome which initially prompted the admission had resolved. There are no physician notes documenting acute symptomatology.  The physician noted the patient had improved and was tolerating medications well. In sum, the inpatient behavioral health services at issue were not medically necessary for treatment of the patients medical condition.  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 psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

A female enrollee requested a positron emission tomography/computed tomography (PET/CT) scan for medical evaluation of her pancreatic cancer.  Findings:  Two physician reviewers found that the current data supports the use of up to three PET/CT scans in solid tumors as the most effective test for diagnosis, staging and evaluation of treatment efficacy.  The physiologic characteristics of PET scans allow for the early detection of recurrence particularly due to the baseline and post treatment scans which are available for comparison.  All told, the PET/CT scan was likely to have been of greater benefit than other modalities for evaluating this patient.
Appeal type: Medical Necessity
Decision: Upheld

A 66-year-old male enrollee has requested Synvisc One or Gel One injection for treatment of his osteoarthritis.  Findings:  The physician reviewer found that it is not medically necessary for this patient to have an additional hyaluronan injection as requested. There have been carefully conducted double-blinded studies, which do not document any clinical effect from hyaluronan injection. In addition, there is a recognized and documented incidence of aseptic inflammatory reactions due to allergic response. This patient has had multiple injections and with each injection and each exposure to the antigen, there is an increased risk of allergic response. There is also a low but present risk of iatrogenic infection within the joint. A recent meta-analysis of the efficacy of viscosupplementation has been performed. This study concluded after review of a total of 89 trials involving 12,667 adults that in patients with knee osteoarthritis, viscosupplementation is associated with a small and clinically irrelevant benefit (Navarro-Sarabia, et al). Several studies evaluating repeated treatment protocols have also reported adverse events including inflammatory changes within the knee joint. All told, the requested Synvisc One or Gel One viscosupplementation injection is not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 41-year-old female enrollee requested authorization and coverage of a mastopexy and buttock lift for the treatment of redundant skin tissue resulting from a substantial weight loss.  The health plan denied the enrollees request indicating that the requested procedures are 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 procedures are reconstructive in nature and are medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:   An enrollee has requested an in office sleep study for evaluation of her medical condition.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  She does not have obstructive sleep apnea, central sleep apnea or mixed sleep apnea.  A repeat polysomnogram in the office is not indicated.  The current medical evidence does not support the requested services in this clinical setting.  All told, the requested in office sleep study is not medically indicated 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 internal medicine with sub-specialty certification in pulmonary disease and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Xolair injections every 4 weeks.Findings: The submitted documentation supports that the requested medication is medically necessary. Xolair is FDA-approved and supported in the asthma treatment guidelines for the management of persisting asthma (despite combined ICS/LABA therapy) in patients with allergic phenotypes based on elevated IgE levels above 30 IU/mL. In this case, the patient has severe, persistent allergic-type asthma despite combined high-potency inhaled corticosteroid and long-acting beta agonist therapy. The patient also has serum IgE levels above 30 IU/mL that suggest an allergic phenotype of asthma. Furthermore, the patient has already demonstrated an excellent response to Xolair with improved asthma control. Under these circumstances, the requested Xolair injections every 4 weeks are medically necessary for the patients medical condition.Final Result: The reviewer determined that the requested medication is medically necessary for the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in internal medicine, with subspecialty certification in pulmonary disease, 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 49-year-old male enrollee has requested authorization a Quickie P222 group 4 power wheelchair for the treatment of his partial quadriplegia. Findings:  The physician reviewer found that this patient requires the use of a power wheelchair in order to perform his mobility-related activities of daily living. The Quickie P222 group 4 power wheelchair meets the patient's in-home needs for the performance of mobility-related activities of daily living. In addition, the requested wheelchair also allows the patient to continue to maintain gainful employment due to its capacity to traverse uneven terrain. The successful prescription of a power wheelchair should consider the entire individual and his or her specific circumstances. In this patients case, the prescribed wheelchair is medically indicated for in-home use.  It is not intended solely for outdoor, recreational or leisure use, and does not exceed the requirements of this patient's condition or circumstances.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested Harvoni for 12 weeks for treatment of his hepatitis C virus (HCV). Findings:  Three physician reviewers found that as per the American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) guidelines, all patients with chronic active hepatitis C are eligible for treatment and should be treated with U.S. Food and Drug Administration (FDA) approved antiviral therapy regardless of fibrosis score. In this case, the patient has advanced stage disease and therefore, it is imperative and medically necessary to treat his HCV infection to potentially eradicate it and prevent further progression and decompensation of his liver disease. Final Result: Three reviewers 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: Reviewer 1 is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. Reviewers 2 and 3 are board certified in gastroenterology 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

The parents of a seventeen year-old female with a history of an eating disorder are requesting reimbursement for the residential treatment services.Reviewers Findings:  The reviewing physician found that due to the patients complexity and underlying problems and an inability to control binging and purging behaviors, the need for residential treatment rather than partial hospitalization program is readily apparent.  The reviewing physician found that the Health Plan denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  The parent of an enrollee has requested partial hospitalization program (PHP) services for treatment of the enrollees behavioral health conditions.  Findings:  The physician reviewer found that in this clinical setting, the PHP services were medically necessary for treatment of the patients behavioral health condition. While the patient was compliant with her meal plan she continued to struggle and had episodes requiring supervision. The submitted records document concerns from the treating providers about the limited professional support to the parents in a complex family dynamic outside of the PHP program. The provider documented that the patient remained at high risk for relapse. The provider also documented that while depression and anxiety have improved, depression was still prominent and her anxiety still present. Transitioning from partial hospitalization in a setting with limited professional services available and few social supports would have been inadvisable for this patient. As such, the PHP level of care services are medically necessary and appropriate in treatment of this patients behavioral health condition.  Final Result: The reviewer determined that the services at issue were 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

Findings:  The physician reviewer found that The patient has requested authorization and coverage for wheelchair accessory, power seat elevation system. Power seat elevation systems are utilized for transferring, reaching, and looking at objects in environments designed for ambulatory patients. Adjusting a patients height when performing these tasks may reduce the onset of pain and comorbidities. The records document that this patient has significant residual limb and phantom limb pain. The patient is limited in ability to perform activities of daily living. Specifically, the patient is having difficulty with wheelchair propulsion, which is likely due to the patients age and injury. On review of the available reports, the patient is not a good candidate for prosthetics. The requested power seat elevation system will enable the patient to view and reach high objects safely and perform transfers all in a manner likely to reduce the patients pain and comorbidities. Moreover, the requested power seat elevation system will help reduce the patients risk of falls. Given these findings, the requested wheelchair accessory, power seat elevation system is medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested equipment is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: A female enrollee has requested authorization and coverage for Norditropin FlexPro 10 mg injections for treatment of the enrollee who has a history of nontoxic multinodular goiter, gastric ulcer and obesity.Findings:  The physician reviewer found that growth hormone deficiency (GHD) is a medical condition in which the body does not produce enough growth hormone (GH).  Recognized effects include reduced muscle mass and strength, reduced bone strength and osteoporosis, decreased energy levels, impaired concentration and loss of memory, increased body fat, lipid abnormalities, and insulin resistance.  Growth hormone deficiency is also appreciated to be a factor in this increased mortality from cardiovascular disease.  GH replacement therapy can provide a number of measurable benefits to GH deficient adults. These include improved bone density, increased muscle mass, decrease of adipose tissue, faster hair and nail growth, strengthened immune system, increased circulatory system, and improved blood lipid levels. In patients with known hypothalamic or pituitary disease, providers can establish the diagnosis of GH deficiency with high sensitivity and specificity when there are three or four additional pituitary hormonal deficiencies or a subnormal IGF-1 level. To establish the diagnosis in patients without these criteria requires provocative growth hormone stimulation. Although this patient seems to exhibit some signs and symptoms, which may be consistent with growth hormone deficiency, she does not effectively meet the necessary criteria to establish this diagnosis.  Her IGF-1, while on the low side, is within normal limits and the submitted records do not appear to indicate any other pituitary hormone deficiencies.  Therefore, Norditropin FlexPro 10 mg injections are not medically necessary for the treatment of this patients medical condition. 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 certification in endocrinology, diabetes and metabolism 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.