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

The patient is a 53-year-old male who is requesting ongoing growth hormone replacement therapy. He has an undocumented history of childhood growth hormone deficiency, which apparently was never treated. He has been diagnosed with adult growth hormone deficiency based on inadequate growth hormone response to clonidine, though the dosage of clonidine involved appears to have been inadequate. The patient began growth hormone therapy in late 2001 or early 2002 and treatment was discontinued or interrupted in August 2004. Based upon the information provided, it is not known how often the patient has been receiving growth hormone therapy in the last six months. The Health Plan has denied coverage for continued growth hormone therapy on the basis it is not medically necessary.The Health Plans denial should be upheld. The submitted records do not provide sufficient evidence to support a diagnosis of adult growth hormone deficiency. The patients response to treatment was subjective with an equivocal biochemical response. The Health Plans recommendation of further diagnostic studies is medically reasonable and appropriate in the case of this patient. An insulin hypoglycemia test should be undertaken by the patients endocrinologist. At this time, there is no medical indication for continued growth hormone therapy. Therefore, I have determined that the requested therapy is 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 parent of a an enrollee has requested authorization and coverage of applied behavioral analysis (ABA) therapy and eight hours per month of supervision for treatment of autism.  Findings: The reviewer found that the request for 15 hours per week of direct ABA therapy and eight hours per month of supervision are medically necessary for treatment of the patients autism. In this case, the patient has made progress with ABA therapy. Per the most recent progress report, he met two goals and made progress with other goals. However, he continues to have issues with elopement and vocal stereotypy. At this time, a reduction of ABA hours is not indicated. This patient needs an increase to 15 hours per week with eight hours per month of supervision. Therefore, the requested hours, as recommended by the patients ABA provider, have been established as medically necessary for treatment of 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 pediatrics with sub-specialty certification in developmental-behavioral pediatrics 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 fifty-three year-old female who was diagnosed with infiltrating ductal carcinoma of the left breast; stage IIA, grade 2, ER/PR positive is requesting reimbursement for BRCA1 and BRCA2 genetic testing.  The patients family history is significant for an identical twin who was diagnosed with breast cancer.  Reviewers Findings:  The reviewing physician found that the American College of Medical Genetics guidelines do not specifically address the patients unique situation of an identical twin diagnosed with breast cancer. However, it can be deduced that identical genetic material imparts equal risk.  The reviewing physician found that the Health Plan denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Overturned

A 38-year-old male enrollee has requested a Dexcom continuous blood glucose monitoring system for the treatment of his diabetes. Findings:  Three physician reviewers found that the device at issue in this case, the DexCom CGMS is approved by the FDA for patients with diabetes mellitus to aid in the detection of episodes of hyperglycemia and hypoglycemia. There is peer-reviewed literature demonstrating that CGMS is no longer experimental/investigational. The device was medically appropriate for this patients Type 1 diabetes mellitus and hypoglycemia unawareness because it detects and prevents life threatening blood glucose fluctuations and other disabling results.
Appeal type: Medical Necessity
Decision: Upheld

A 37-year-old female enrollee requested authorization and coverage of continued orthopedic spine treatment (OST).  The health plan denied the request, indicating that the requested services are not medically necessary for treatment of the enrollees speech therapy. One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer upheld the health plans denial on the basis that the requested therapy is not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 47-year-old female who had bilateral hip surgery in April 2005. Preoperatively she had a low normal hematocrit of 37.3%. In an effort to avoid transfusion, four doses of Procrit were prescribed. The Health Plan reportedly covered the first two injections but not the last two injections. The patients request for reimbursement for the cost of the last two Procrit injections was denied by the Health Plan based upon a determination that the therapy was not medically necessary.The patients provider likely recommended preoperative treatment with Procrit due to the greater blood loss anticipated with bilateral hip surgery. When this potential blood loss is considered in light of a hematocrit barely within the normal range and the prior authorization of the initial two injections, I believe that completion of the prescribed Procrit injections was medically appropriate. Therefore, I have determined the therapy at issue was medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for the residential behavioral health treatment for treatment of the enrollees polysubstance abuse. Findings:  The physician reviewer found that In cases such as this, an evidence-based, objective, instrument such as the Level of Care Utilization System (LOCUS) is indispensable in determining the appropriate level of care for adults, to insure their level of care meets their individual needs, safely and effectively, in the least restrictive setting possible. The patient demonstrated a low risk of harm (score 2) due to a lack of current suicidal ideation and her functional status was moderate (score 3) given her intact activities of daily living but she had a history of issues with daily functioning due to theft. The patients medical, addictive and psychiatric co-morbidity were moderate (score 2) due to overall medical stability, some substance abuse issues, anxiety, and kleptomania symptoms. The patients recovery environment was mildly stressful (score 2) with a stable living environment, and her level of support was supportive (score 2) due to an overall supportive recovery environment with her family. The patients treatment and recovery history was moderate (score 3) with minimal treatment response in the past but also a minimal past history of treatment. The patient was noted to be cooperative and engaged in treatment (score 2) with apparent insight into her need for treatment. This gives the patients presentation a composite score of 16, which correlates with high intensity community based services such as intensive outpatient program (IOP) treatment. Given these findings, the residential behavioral health treatment provided were not medically necessary for treatment of this patients behavioral health condition. Final Result: The reviewer determined that the services at issue were not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 39-year-old female enrollee has requested a spinal fusion with total disc arthroplasty (22856), arthrodesis (22551) and anterior instrumentation (22845) for treatment of her neck pain and degenerative disc disease.  Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the requested procedures. The patient has chronic neck pain, however she has no localizing features to her neck pain. The patients reported symptoms of neck pain radiating to the left eye and down medial aspect of her left arm and hand do not follow a defined neuroanatomic pathway. According to Bambakidis and colleagues, cervical radiculopathy or myelopathy are the main indications for surgical fusion of the cervical and lumbar spine. Other accepted criteria include instability, infection, tumor, fracture, and spinal stenosis with evidence of spinal cord compression or nerve root compression which correlates with the clinical examination (Bambakidis et al). In this patients case, she does not have cervical radiculopathy or cervical myelopathy or any of the accepted criteria listed above. Thus, the requested procedures are not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested Harvoni for treatment of the enrollees chronic hepatitis C virus with unknown genotype.  Findings: The physician reviewer found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C, regardless of fibrosis, should be treated except those with limited life expectancy due to non-liver-related comorbid conditions. Per the guidelines, Harvoni is a recommended regimen for certain hepatitis C genotypes, but not others. For example, the medication would not be appropriate for treatment of genotypes 2 or 3, while it may be appropriate for genotypes 1 or 4 (Kowdley, et al; Keating, et al). Cure of hepatitis C is indicated, as AASLD/IDSA guidelines cite data showing increased survival with earlier treatment (Jezequel, et al). However, although treatment of hepatitis C is needed, the requested treatment with Harvoni for 12 weeks is not supported as medically necessary based on the information provided.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 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for continued inpatient mental health treatment from 2/28/16 through 3/01/16.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  On 2/28/16, the patient did not have any suicidal or homicidal ideation.  The patient did not have any psychosis, mania, delusions, hallucinations, or agitation.  The patient was calm, cooperative, and engaged in groups.  She was sleeping well and was compliant with medications. The patient was medically stable and did not require 24-hour monitoring. The patient had a supportive environment to return to after discharge. The patient continued to require treatment, but this could have been done in a less restrictive environment such as an intensive outpatient program.  Final Result: The reviewer determined that the services at issue were not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 34-year-old female enrollee has requested reimbursement for residential care provided for treatment of the enrollees substance abuse.  Findings:  The physician reviewer found that based on review of the available records, this patient is a relatively healthy young woman with a history of chemical dependence. She was successful in her remission of alcohol dependence but subsequently has used opioids for the last two years while suffering from the loss of her father as well as a painful urological condition. The records indicate that the patient was already stabilized on Suboxone and had no acute medical or psychiatric instability at the time of admission. Applying the American Psychiatric Association (APA) and the American Society of Addiction Medicine (ASAM) treatment guidelines, patients such as this are typically managed safely and effectively in an intensive outpatient program (IOP) or partial hospitalization program (PHP) so they can reside in a near normative environment while dealing with chronic co-morbid problems. Given the patients previous successful remission and her lack of acute medical or psychiatric issues, the residential level of care services provided were not medically necessary for management of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

A female enrollee requested the AlloMax surgical graft used during a breast reconstruction procedure for medical treatment of her bilateral Grade IV capsular contracture. Findings:  Two physician reviewers found that Busse and colleagues stated that some of the key benefits of AlloMax as compared to AlloDerm are the shorter preparation time, terminal sterility, and the fact that no orientation is necessary for implantation. Additionally, an article by Carruthers and colleagues stated that AlloMax incorporated more readily with surrounding host tissue as measured by earlier and greater cell infiltration, fewer foreign body giant cells, and faster remodeling of acellular dermal matrices. The authors concluded that these findings correlated with the in vitro composition and cytocompatibility analysis, which showed AlloMax to more readily support in vitro cell growth. For these reasons, the AlloMax surgical graft was likely to have been more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld

A 54-year-old female enrollee has requested authorization and coverage for a third series of Orthovisc injections for treatment of the enrollees degenerative joint disease of the knee.  Findings:  The physician reviewer found that the value of viscosupplementation in the treatment of osteoarthritis of the knee has generally been accepted. It is most effective in patients with mild to moderate involvement.  As noted by Gossec and Dougados, this treatment is most efficacious in patients with non-radiologically severe osteoarthritis, with no or mild effusion. It is much less effective for patients with moderate to severe disease. The effect of multiple courses of treatment is unclear, with a lack of sufficient evidence to reach firm conclusions. Some reports of repeat courses of treatment have been encouraging, but there have also been reports of increased problems with more than one course of treatment.   At this time, additional high-quality randomized studies are needed to define the role of intra-articular hyaluronate injections in the treatment of osteoarthritis.  The current medical evidence does not support the requested services in this patients case.  All told, the requested third series of Orthovisc injections are not medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

The enrollee requested reimbursement for positron emission tomography - computed tomography scan. The enrollee has a dermoplastic malignant melanoma in the mid-portion of his back. A sentinel node biopsy was not possible due to the size of the surgical resection. A positron emission tomography scan was normal. A follow- up positron emission tomography  computed tomography scan was normal, except for faintly seen gallstones. A follow-up visit showed no evidence of recurrence or metastasis. The enrollee reports the positron emission tomography was ordered for restaging, and as a comparison to a prior scan. Researchers report that follow-up involves a comprehensive history and physical every six to twelve months for two to five years, and then decreasing follow-ups to annually. No imaging is recommended as part of the routine follow-up. Researchers recommended against surveillance imaging for asymptomatic enrollees with stages 1A, 1B, and 2A.Final Result: Three of the three reviewers determined that the requested services were not likely to have been more beneficial than any available standard therapy for treatment of the enrollees medical condition. Credentials/Qualifications: Three reviewers are board certified in medical 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: Medical Necessity
Decision: Overturned

A 52-year-old male enrollee has requested for DEXA bone density testing for evaluation of her low bone mass. Findings:  The physician reviewer found that it is well-documented in the peer-reviewed literature that follow-up bone density scans performed on a different DEXA machine may not be as accurate as those follow-up studies performed on the same equipment. This is due to the use of different DEXA equipment in addition to the use of similar DEXA equipment which cannot be calibrated in an identical manner. To properly treat patients with known low bone density, it is imperative to have accurate data on the follow-up DEXA scan. The American College of Radiology states that the most valid follow-up DEXA scan is on the same device.
Appeal type: Medical Necessity
Decision: Overturned

An enrollee has requested authorization and coverage for quetiapine extended-release 150 mg tablets. The U.S. Food and Drug Administration has approved quetiapine XR as a monotherapy for the treatment of acute depressive episodes of bipolar disorder and acute manic or mixed episodes in bipolar I disorder based on two placebo-control trials. One study demonstrated that subjects on quetiapine XR showed a statistically significant decline in total Young Mania Rating Scale (YMRS) scores compared to placebo. In terms of the side effect profile, there is evidence that patients taking Seroquel XR experience less sedation than Seroquel IR. In this case, the patient has failed to respond to many antipsychotics and has been unable to tolerate the sedation side effects of Seroquel IR. Under these circumstances, quetiapine extended-release 150 mg tablets are medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested medication is medically necessary to treat 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested bilateral breast tomosynthesis for evaluation of her medical condition.  Two physician reviewers found that in this patients case, the services at issue were likely to have been superior over other available modalities.  The current medical evidence supports the services at issue in this clinical setting.  Per the literature, the addition of digital breast tomosynthesis to mammography has proven to be very useful to radiologists interpreting mammography.  Breast tomosynthesis has been associated with a decrease in callbacks and increase in detection of small cancers.  All told, bilateral breast tomosynthesis was likely to have been more effective than other methods of evaluation.  Final Result: Two reviewers determined that the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: All three reviewers are board certified in diagnostic radiology and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.