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

The patient has requested reimbursement for OxyContin 20 mg (one tablet every 12 hours; #28 tablets for two week supply). The guidelines from the American Pain Society and American Society of Regional Anesthesia and Pain medicine support acetaminophen and/or nonsteroidal anti-inflammatory drugs (NSAIDs) as part of multimodal analgesia for management of postoperative pain in patients without contraindications. In this case, the patient was treated with OxyContin following L4-5 interbody fusion for lumbar spondylolisthesis with lumbar spinal stenosis and neurogenic claudication. The provider noted that the spinal fusion was a contraindication for the use of NSAIDs due to healing of the bone fusion. The provider noted that other modes of analgesia were unsuitable. The provider recommended postoperative pain management with OxyContin 20 mg for two weeks. This short course of a long-acting pain medication to assist with the patients increased levels of pain in the immediate postoperative period was reasonable and individualized to the patients medical condition. Given these findings, the OxyContin 20 mg (one tablet every 12 hours; #28 tablets for two week supply) was medically necessary for treatment of this patient. Final Result: The reviewer determined that the medication at issue was 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 anesthesiology with subspecialty certification in pain management 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 male enrollee requested residential chemical dependency services for medical treatment of his substance abuse.  Findings:  The physician reviewer found that there is a lack of evidence submitted for review demonstrating that 24-hour supervised care was required to prevent decompensation.  The patient had a sober support system. He had no history of prior treatment and no indication that he would not respond to a lower level of care. Based on the medical literature cited above and the documentation submitted for review, the services at issue were not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

An 18-year-old male enrollee has requested reimbursement and continued authorization and coverage for partial hospitalization services for treatment of the enrollees depression and anxiety. Findings:  The physician reviewer found that current psychiatric practice aims to place patients in the least restrictive treatment setting, as this practice consolidates treatment gains and facilitates enduring recovery.  The documentation provided fails to support treatment at the partial hospitalization level of care. There is no comprehensive treatment plan structuring the partial hospitalization and articulating the treatment goals, objectives and clinical path necessary for a seamless transition to a less restrictive setting. Further, the patients motivation and the appropriateness of partial placement must be considered as the patient was absent from the program on several dates and was late on several more.  Considering the patients clinical presentation and the documentation provided for review, the services at issue were not and are not medically necessary for treatment of the patients medical.  Therefore, the Health Plans denial was appropriate.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage of Epclusa for 12 weeks for treatment of the enrollees hepatitis C virus. Findings: The physician reviewer found that according to joint guidelines issued by the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America, all patients with chronic hepatitis C should be treated except those with life expectancy less than 12 months due to non-liver-related conditions. This applies regardless of fibrosis stage, and advanced fibrosis is not required for treatment. Per the guidelines, Epclusa is recommended as first line therapy for treatment naive genotype 2 patients, based on clinical trials including ASTRAL-1 and ASTRAL-2, which showed a 99% cure rate and superiority to Sovaldi with ribavirin. Delay in treatment may result in decreased survival. For these reasons, Epclusa is supported as medically necessary for the treatment of this patients hepatitis C infection.Final Result: The reviewer determined that  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: Medical Necessity
Decision: Upheld

The parent of a three-year-old female has requested speech therapy for treatment of apraxia and sensory integration dysfunction.  Findings:  The physician reviewer found that the diagnosis of childhood apraxia of speech is controversial, as is its etiology.  There are numerous theories as to the cause of childhood apraxia, but none are established in peer- reviewed journals. The medical necessity of speech and language therapy for childhood apraxia of speech has not been established.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested the LINX reflux management system for treatment of her medical condition.  Findings: Two physician reviewers found that the submitted documentation supports the requested services in this patients case.  The LINX reflux management system has been approved for lower esophageal sphincter augmentation.  Appropriate candidates for the procedure include those with inadequate symptom control with acid suppression therapy, including those patients with mild to moderate gastroesophageal reflux disease and a hiatal hernia less than 3 cm. This patient meets those specific criteria.  There is sufficient support for the requested services in this clinical setting.  Therefore, the requested LINX reflux management system is likely to be more efficacious than other treatment options.  Final Result: Two reviewers determined that the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications:  All three physician reviewers are board certified in internal medicine with sub-specialty certification 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The enrollee has requested reimbursement for the Prometheus Anser ADA test for measurement of serum antibodies to adalimumab for evaluation of the enrollees ulcerative colitis. Findings:  The physician reviewer found that Monitoring patients on Humira with measurement of Humira levels and antibodies to Humira continues to be an area of intense investigation. Some data suggests that Humira levels correlate inversely with disease activity. However, there is a lack of controlled data which have identified the optimal drug level. Given the paucity of peer-reviewed medical literature supporting the clinical utility of the Anser ADA test in this circumstance, the Prometheus Anser ADA testing for measurement of serum antibodies to adalimumab performed was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: All three reviewers determined that the testing at issue was 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: Physician reviewer number one 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.Physician reviewer number two 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.Physician reviewer number three 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: Medical Necessity
Decision: Overturned

The patient has requested authorization and coverage for rhinoplasty, as part of facial feminization surgery. The World Professional Association for Transgender Health (WPATH) Standards of Care (SOC) acknowledges that, for certain patients, an intervention like a reduction rhinoplasty can have a radical and permanent effect on their quality of life, and therefore is much more medically necessary than for somebody without gender dysphoria. WPATHs SOC further states that although facial feminization procedures are labeled purely aesthetic, these procedures in an individual with severe gender dysphoria can be considered medically necessary, depending on the unique clinical situation of a patients condition and life situation. Facial feminization surgery provides reconstructive surgical services for an abnormality as a result of the disorder of gender dysphoria. The outcome of reconstructive surgery would enhance this patients psychological and social functioning. This patient has a documented history of gender dysphoria and has had genital and other facial feminization gender confirming surgeries. Based on the current medical literature, the requested rhinoplasty, as part of facial feminization surgery, is medically necessary for treatment of this patient. 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 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: Upheld

A 42-year-old female enrollee requested authorization and coverage of skin excision and revision abdominoplasty. The Health Plan denied the request indicating that the requested procedure is not medically necessary for treatment of the enrollees excess skin.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested procedure is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 60-year-old female with metastatic breast cancer. She underwent gamma nail to the left hip. The patient also has persistent anemia. She has progressed well in the hospital with less than 120 minutes of occupational and physical therapy daily. She requires contact guard assist to ambulate and minimum assistance with transfer. She is able to ambulate more than 250 feet. She needs standby assistance or is independent with ADLs. It appears her pain is under control. The patient has requested coverage for additional acute rehabilitation services. The Health Plan has denied the request on the basis the requested services are not medically necessary.Review of the submitted documentation does not demonstrate the patient requires intensive occupational/physical therapy at an acute rehabilitation level. It appears the patient is stable for transport to another facility for radiation. The patients medical needs are not at an inpatient level, except for hydration. She does require frequent monitoring and rehabilitation for her hips. These services can be provided at a skilled nursing facility that is equipped to monitor her frequently. As such, the services authorized by the Health Plan are medically reasonable and appropriate.Based upon the information set forth above, I have determined that the requested services are not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of a female enrollee has requested reimbursement and prospective authorization and coverage for services offered by the Scoliosis Academy and Janzen and Janzen Health Center for treatment of the enrollees scoliosis. Findings:  2/3 of the physician reviewers found that there is sufficient support in the body of literature as well as the documentation provided for the services at issue in this clinical setting. The patient has shown significant improvements in the curvature following the treatments at the Scoliosis Academy and Janzen and Janzen Health Center. The current medical literature also supports the combined treatments of three dimensional bracing and Schroth physiotherapy exercises. The current conservative treatment plan resulted in objective functional improvements. There is a lack of alternative options available for treatment of this patient except for surgery and in this case, surgery is not recommended due to the patients age, medical, and physical condition. Accordingly, the services offered by the Scoliosis Academy and Janzen and Janzen Health Center were and are likely to be more effective than other modalities available for treatment of this patients medical condition. Final Result: 2/3 of the 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 should be overturned. Credentials/Qualifications: Physician reviewer number one is board certified in chiropractic care 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 chiropractic care 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 chiropractic care 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 enrollee has requested authorization and coverage for MLH1, MSH2, MSH6, and PMS2 full sequence and duplication/deletion variants gene analysis (CPT codes 81292, 81294, 81295, 81297, 81298, 81300, 81317, and 81319) for evaluation of the enrollees risk for cancer. Findings:  Two physician reviewers found that a patient should be tested for hereditary colon cancer Lynch syndrome if a personal or family history indicates that the patient may be at an increased risk for Lynch syndrome, genetic test results provide the most accurate way to assess that patients cancer risk. Genetic testing for hereditary colon cancer Lynch syndrome should be considered if the patient has a history of colorectal or endometrial cancer before age 50, colorectal cancer with MSI-high histology before age 60, mucinous, Signet ring, tumor infiltrating lymphocytes, Crohns-like lymphocytic reaction histology, or medullary growth pattern. Testing is also indicated for patients with a family history of two or more relatives with a Lynch syndrome cancer with one before the age of 50, three or more relatives with a Lynch syndrome cancer at any age, or has a previously identified Lynch syndrome mutation in the family. None of these conditions apply to this patients personal family history. Final Result: Two reviewers determined that the requested testing is 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: All three physician reviewers 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 17-year-old female enrollee requested partial hospitalization program for medical treatment of the enrollees anorexia nervosa.  Findings:  The physician reviewer found that this patient evidenced significant psychiatric impairment stemming from an eating disorder with co-occurring anxiety and mood symptomatologies.  In reviewing the clinical documentation, partial hospitalization services were safe, appropriate and aimed at optimizing the skills needed to succeed in the outpatient setting.  Further, the services provided were for both purposes of diagnosis and active treatment.  Additionally, the services were reasonably expected to improve her condition and prevent a more serious episode of illness.  All told, partial hospitalization program services were medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

A 34-year-old male enrollee has requested orthognathic surgery for the treatment of his mandibular underdevelopment. Findings:  The physician reviewer found that the submitted clinical evidence demonstrates this patient has a maxillofacial skeletal malformation which has resulted in mandibular hyperplasia with a significant overjet. The patient has a functional deficit in that he has difficulty with mastication. Given the degree of his mandibular hyperplasia, orthognathic surgery is indicated and will result in improved mastication and swallowing and improved musculoskeletal, dento-osseous and soft tissue relationships.
Appeal type: Medical Necessity
Decision: Upheld

A 22-year-old female enrollee has requested gastric bypass surgery (Lap-Band) for treatment of her morbid obesity and endometriosis. Findings:  The physician reviewer found that based on review of the available records, this patient is morbidly obese. However, the medical necessity of the requested bariatric surgery cannot be determined based on generally accepted guidelines given the information provided. Applying the National Institutes of Health (NIH) consensus guidelines, documentation of a thorough multidisciplinary evaluation that includes behavioral and dietary evaluations as well as ruling out treatable metabolic causes of obesity with a thyroid stimulating hormone (TSH) level needs to be provided for review. Thus, although the patient states that she has failed dietary efforts in the past, there is limited evidence in the records consisting of one note from the patients primary care provider and a program summary without specific details of the patients weight loss attempts. In the absence of this required information, the requested surgery cannot be approved at this time although it should be noted that the patients BMI meets the criteria for bariatric surgery should she complete the requisite multidisciplinary evaluation.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for partial hospitalization program services. The submitted documentation fails to demonstrate the medical necessity of the services at issue. The recent records indicate the patient was cooperative in her meal planning. She reported some binging behaviors, but her understanding of her need for treatment appeared intact. She was noted to be adherent to her medication regimen and was cooperative with psychiatric treatment. The progress notes did not document other severe psychiatric symptoms. It appears that she was exhibiting some purging behaviors, but her weight remained close to 100% ideal body weight.The American Association of Community Psychiatrists Level of Care Utilization System (LOCUS) for Psychiatric and Addiction Services is an evidence-based, objective, instrument used to determine the necessary level of care for adults. With regards to risk of harm, the records support a score of 1-2. The records noted a lack of current suicidal ideation and no self-harming behaviors. In terms of functional status, the records support a score of 2. There were some problems with job performance. With regards to medical, addictive and psychiatric comorbidity, the records support a score of 2 due to overall medical stability. In terms of recovery environment, level of stress, the records support a score of 3. The patient had a stable living situation. With regards to recovery environment, level of support, the records support a score of 2. The documentation noted family support and availability of treatment resources. In terms of treatment and recovery history, the records support a score of 3 due to recent success at the residential treatment level of care. With regards to engagement and recovery status, the records support a score of 2 due to cooperation in treatment and insight into her need for treatment. Thus, the patient has a composite score of 15-16. This score correlates with community based treatment in the outpatient clinic setting. The literature indicates that outpatient treatment with modalities such as cognitive behavioral therapy can be effective for treatment of eating disorders. All told, partial hospitalization program 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.