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

The patient is a 65-year-old female with a history of chronic depression, interstitial cystitis, and chronic fatigue syndrome for approximately a two-year period after extensive dental work and a subsequent infection that took seven weeks to remit. The patient has been homebound spending most of the day in bed due to the extent of the fatigue. She recently developed chronic diarrhea and gastritis that is being followed by gastroenterology. Though the patient indicates she participated in many trials of medications, it is unclear which medications she has taken short of the more recent Celexa and Trazodone. She also sees a therapist with whom she has been in treatment for many years. Her therapist has deemed it vital that the patient continue in supportive counseling to keep her from feeling alone, depressed, and frightened. Some of the therapists notes indicate things such as having symptoms of stress again-pulling hair, chewing rubber bands, eating uncontrollably, hasnt been cleaning the house or crying a lot, feeling very alone. A request has been made for continued outpatient therapy sessions. The Health Plan has denied the request indicating that the patient has been in therapy from 2002 to mid-2004 and is not likely to improve with continued therapy. Based upon the information provided, the patient is significantly depressed and anxious and outpatient therapy has been ineffective. In addition, a good portion of therapy actually preceded the more significant decline of the patient in the past two years. Furthermore, though the patient has also been in treatment with a psychiatrist, it is unclear just how aggressive a course of medicinal treatment she has had for her depression. Given that the patient is still seriously depressed despite years of outpatient therapy, and since attempts at medicinal treatment have not been exhausted, I have determined the requested services are not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for brand name Copaxone 40 mg/mL injected subcutaneously three times per week. Findings:  The physician reviewer found that Multiple sclerosis is a progressive immune disease affecting the central nervous system, causing neurological dysfunction. Multiple sclerosis is characterized by multifocal inflammation of the central nervous system, which causes impaired nerve conduction. Current medical literature directing treatment for multiple sclerosis supports treatment with Copaxone as used in this patients management and care. The provider noted that the patient has experienced stable disease while treated with Copaxone. The generic version of Copaxone reportedly resulted in side effects, which supports treatment with brand name Copaxone. Considering the patients stability on brand name Copaxone, and clinical adverse effects experienced with a generic substitute, continuation of brand name Copaxone is appropriate. Therefore, the requested brand name Copaxone 40 mg/mL injected subcutaneously three times per week is medically necessary for treatment of this patients medical condition.Final Result: The reviewer determined that the requested brand name 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 neurology with subspecialty certification in vascular neurology 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 32-year-old female has requested coverage for residential treatment program services for approximately four weeks for treatment of her anorexia nervosa, purge type, and major depressive disorder, recurrent, moderate.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue in this patients case.  The aim of modern psychiatry is to provide effective interventions in the least restrictive setting, as treatment in the community is consistent with better outcomes.  In this patients case, the records demonstrate acute-on-chronic eating disorder with co-occurring mood and anxiety symptomatologies.  However, there is no evidence that this motivated patient required the structure and supervision of a 24-hour setting, and there is no documentation indicating that she had recently failed less restrictive settings, such as partial hospitalization or intensive outpatient programming.  The current medical evidence does not support the services at issue in this case.  All told, residential treatment program services were not medically indicated.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollees parent has requested authorization and coverage for ABA services, including 40 hours per week of direct therapy (24 hours in school and 16 hours in home), 30 hours per month of supervision and six hours per month of parent training, for six months. The submitted documentation supports the medical necessity of the requested services. In this case, a lack of progress, and subsequent increase in interfering behaviors, coincided with the patient attending kindergarten and an interruption in services for approximately two months at the start of the school year. The purpose of supporting the patient in the educational setting is to provide training on social interactions with peers. The Behavior Analyst Certification Board (BACB) indicates that services are provided in multiple locations, including school settings, to promote generalization and maintenance of treatment gains. In this case, it has been observed that a decrease in service intensity has led to an increase in problem behavior and slow progress. This patients Vineland Adaptive Behavior Scales, Third Edition scores were discrepant from her same-age peers. Specifically, the patients total composite was greater than one standard deviation below the mean, and the socialization domain was two standard deviations below the mean. ABA therapy is the most evidence-based treatment for children and adults on the autism spectrum. One of the ABA strategies identified among the evidence is naturalistic teaching, which utilizes ABA therapy in naturally occurring contexts, such as the school. The school environment grants the patient natural opportunities to evoke, generalize, and maintain the desired behavior. Therefore, the requested ABA services, including 40 hours per week of direct therapy (24 hours in school and 16 hours in home), 30 hours per month of supervision and six hours per month of parent training, for six months are medically necessary for the 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 neurology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the Botox injections. Findings:  Three physician reviewers found the Botox injections were likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Pooled results of two large, randomized, placebo-controlled trials show that Botox is an effective, safe, and well-tolerated treatment for the prevention of headache for patients with chronic migraine. In addition Botox has been approved by the U.S. Food and Drug Administration  for headache prophylaxis in patients with adult chronic migraine who suffer headaches on 15 or more days per month, each lasting more than four hours. The medical records report that this patient is having chronic headaches, migraine type, on an ongoing basis demonstrating headaches lasting four or more hours on 15 days or more per month for at least three months. Given these findings, the Botox injections were likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the Botox injections were likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in neurology 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

The patient is a 50-year old male who has a history of atrial fibrillation and possible prior angina or coronary artery disease (CAD).  He underwent a non-contrast electron beam computerized tomography (EBCT) scan of the heart in January 2005. At the same time, non-contrasted CT scans of the pelvis and abdomen were performed for screening for prostate cancer. The Health Plan has denied coverage for these diagnostic imaging services based on a lack of medical necessity.EBCT is not currently recommended as a screening test for CAD by the American College of Cardiology or the US Preventative Services Task Force.  For high-risk patients, non-invasive risk stratification with a myocardial perfusion agent is recommended. Once prior CAD has been established, an EBCT offers little more in terms of treatment direction. Thus, the use of EBCT scanning in this case was without clinical value and therefore, not indicated.Regarding the CT scans of the pelvis and abdomen, although CT scanning is often used to determine if metastatic disease is present, non-contrasted screening scans as were performed in this case, are of limited value and do not exclude the possibility of metastasis. The documentation provided does not clearly indicate the level of concern for prostate cancer or what other test results (bone scan, x-rays) identified the need for CT scanning. If a CT scan were indicated, a non-contrasted scan for tumor would not normally be the first step and therefore, the CT scans of the pelvis and abdomen were not medically warranted.Based upon the information set forth above, I have determined the diagnostic imaging at issue was not medically necessary for evaluation of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

A 47-year-old female enrollee has requested allergen specific IgG testing (CPT code 86001) for evaluation of her celiac disease and chronic sinus infections. Findings:  Three physician reviewers found that the submitted documentation noted that the patient underwent IgG testing for multiple foods in said date.  In vitro IgG testing for food allergies is generally not accepted by practitioners as standard medical care.  IgG test results are not considered to be of clinical value. In this case, allergen specific IgG testing was not likely to be the most efficacious method of evaluating this patient.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested three-dimensional breast tomosynthesis for evaluation of her medical condition.  Findings:  Three physician reviewers found that breast tomosynthesis is a technique that was developed several years ago as a problem solving adjunct to routine mammography.  Applying the same basic concept as computed tomography (CT) scanning, the logic is that by separating the various layers of breast tissue, one can better detect abnormalities.  This has been shown to be most useful in the evaluation of dense breasts.  As noted, breast tomosynthesis has the potential to change conventional mammographic screening and diagnostic imaging with possible improvements in cancer detection, decreased callbacks, and fewer false positive biopsies.  Medical terminology noted that the addition of tomosynthesis to digital mammography was associated with a decrease in recall rate and an increase in cancer detection rate.  It is specifically those patients who have dense breasts that can benefit most from tomosynthesis. The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor.  Thus, three-dimensional breast tomosynthesis was likely to have been more effective than other methods of evaluating this patient.Final Result: Three physician 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 physician 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: Overturned

A 61-year-old female enrollee requested authorization and coverage of the medication Clarinex. The Health Plan denied the request indicating that the requested medication is not medically necessary for treatment of the enrollees allergies.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plans denial on the basis that the requested medication is medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

The parent of an 18-year-old female enrollee has requested psychiatric residential treatment services for treatment of the enrollee's behavioral health problems.   Findings:  The physician reviewer found that based upon the evidence provided, the patient was ready to step down to a less intensive level of care after the date in question. She received an effective clinical intervention at the residential level of care from a specialized eating disorder program.  She reached a weight that was safe for her to be transferred to a less intensive level of care, but continued to demonstrate evidence of a chronic eating disorder with loss of calcium from her bones. As such, an appropriate step-down from the residential treatment eating disorder program was a PHP eating disorder program.
Appeal type: Experimental/Investigational
Decision: Upheld

A 19-year-old male enrollee has requested bariatric sleeve gastrectomy for treatment of his morbid obesity. Findings:  Three physician reviewers found that bariatric surgery is medically indicated in this patient who is morbidly obese with a BMI of 54. However, the patient does not have significant comorbid conditions such as diabetes warranting a two-staged procedure like sleeve gastrectomy followed by a restrictive procedure. A standard bariatric surgical procedure is medically reasonable and appropriate in this clinical setting.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Mono HDR Brachytherapy.The medical literature supports that the requested Mono HDR Brachytherapy is medically necessary. Current guidelines state that brachytherapy can be used as a standard treatment option in patients. Long term data on patients treated with brachytherapy alone show that they have equivalent outcomes to conventional external beam radiation therapy.  Brachytherapy is considered a standard treatment option for patients with intermediate prostate cancer and has been endorsed by guidelines for over 20 years.In this case, the patient has favorable intermediate risk prostate cancer. The medical literature supports that Brachytherapy is a standard treatment option for patients with intermediate prostate cancer. Under these circumstances, the requested Mono HDR Brachytherapy is medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in radiation oncology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a Dexcom continuous glucose monitoring (CGM) system. According to the Diabetes Control and Complications Trial (DCCT), diabetes related complications can be delayed or prevented with better diabetes control and hemoglobin A1C of around 7%. This patient has diabetes type 2 but he is insulin deficient and is managed with multiple insulin injections, basal insulin and premeal insulin, which he self-adjusts based on glucose readings and food intake. He has poor diabetes control and wide glucose fluctuations and hypoglycemic tendencies. As a result of longstanding suboptimal control he has diabetes related complications, nephropathy and neuropathy, which places him at higher risk for hypoglycemia unawareness and hyperglycemia. In order to optimize management and improve his prognosis, the requested Dexcom CGM is medically necessary for this patient. Final Result: The reviewer determined that the requested device 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 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.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for long acting morphine or one of the following long lasting opioids: Avinza, Exalgo, Nucynta, OxyContin, Palladone, and oxymorphone HCL for treatment of the enrollees pain. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medications. This patient appears to have opioid-induced hyperalgesia rather than tolerance since her pain has been increasing on higher dosages of potent opiates.  She has several risk factors that put her at increased risk for opiate complications, such as suicidal ideation, depression and self-escalation of medications, and these factors support the need for non-opiate pain therapy. Switching to extended release opiates to do a taper is not medically appropriate. All told, long acting morphine or one of the following long lasting opioids: Avinza, Exalgo, Nucynta, OxyContin, Palladone, and oxymorphone HCL are not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medications 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 anesthesiology 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: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage of Vemlidy 25 mg tablets. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees hepatitis B virus. Findings: The physician reviewer found that the guidelines for the treatment of hepatitis B from the American Association for the Study of Liver Diseases (AASLD) recommend entecavir and tenofovir compared with alternatives for the treatment of chronic hepatitis B. In comparison with tenofovir disoproxil fumarate (Viread), which the patient is taking, the Vemlidy formulation of tenofovir is effective for treatment of hepatitis B but is associated with lower incidence of side effects such as osteopenia and renal disease. For this reason, Vemlidy 25 mg is medically necessary for the treatment of this patients hepatitis B. 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 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

A 59-year-old female enrollee has requested continued use of Evista 60mg for the treatment of her osteoporosis. Findings:  The physician reviewer found that combination therapy with Miacalcin and Evista has not been studied to prevent or treat postmenopausal osteoporosis. The fact that the patient had improvement in her DEXA scan in the lumbar spine is consistent with the effects of these agents in their ability to prevent vertebral fractures. However, data is not available to support the use of these two agents in combination. Based on the medical records submitted, the indication for using Evista as it relates to breast cancer does not support its use for preventing recurrent disease, which is an argument that is presented in support of the combination therapy. Continued use of Evista 60mg daily in combination with Miacalcin is not medically indicated for the patients condition of postmenopausal osteoporosis. Either medication as monotherapy would be appropriate treatment for this patient.