Persius/imr-appeals huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Upheld

A 64-year-old male enrollee requested authorization and coverage of the medication procrit  for the treatment of fatigue.  The health plan denied the enrollees request indicating that the requested treatment is experimental.Three physician reviewers performed an experimental/investigational Independent Medical Review.  Each of the three physician reviewers concluded that the medication procrit is not likely to be more beneficial for treatment of the enrollees fatigue than any available standard therapy.  Because all three physician reviewers concluded that the requested treatment is not likely to be more beneficial for treatment of the enrollees medical condition than any available standard therapy, the review organization upheld the health plans denial.
Appeal type: Medical Necessity
Decision: Overturned

A 50-year-old female enrollee has requested a bariatric surgery consultation for the treatment of her morbid obesity. Findings:  The physician reviewer found that the medical literature has clearly demonstrated the benefit of weight loss surgery for patients such as this patient. Weight loss surgical procedures have different outcomes based on the type of the operation performed. This patient should be authorized to seek a surgical consultation for weight loss surgery and undergo treatment based on her treating surgeons recommendation.
Appeal type: Medical Necessity
Decision: Upheld

A 38-year-old male enrollee requested authorization and coverage of a full-body scan. The Health Plan denied the request indicating that the requested full-body scan is not medically necessary for evaluation of the enrollees pain. One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested full-body scan is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

A fifty-one year-old obese female with significant comorbid conditions including type 2 diabetes, diabetic neuropathy, asthma, irritable bowel syndrome, hypothyroidism and hypertension is requesting coverage for bariatric surgery.  Reviewers Findings:  The reviewing physician found that the patients preoperative work up is by no means complete. There is no evidence in the record that she has consulted with a surgeon, obtained psychological clearance or obtained clearance from a gastroenterologist.  The reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential treatment services provided for treatment of the enrollees alcohol use disorder. Findings:  The physician reviewer found that based on the available documentation, the residential treatment services provided from were not medically necessary for treatment of this patients medical condition. The patient was not experiencing post-acute withdrawals, he was not a danger to himself or others, and there were no emotional, behavioral, cognitive, or impulsive symptoms that would warrant this level of care. He was medically and psychiatrically stable to the extent that he did not need residential level of care. Vivitrol could have been administered on an outpatient basis. He was engaged and participated in his treatment plan, was looking for a sponsor, and he was insightful. The issues he was working on in individual therapy that centered around his family relationships did not need to be addressed in residential treatment. His recovery could have continued on an ambulatory basis in a less restrictive treatment setting. 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 with sub-specialty certification in addiction medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 42-year-old male enrollee has requested for SPECT scans for evaluation of his brain trauma, general anxiety disorder, attention deficit disorder, inattentive type, and mood disorder, not otherwise specified. Findings:  Three physician reviewers found that SPECT scans did not add any significance to the evaluation and did not direct treatment that would not already be indicated. Its approved usage involves evaluating and monitoring structural brains disorders such as stroke, seizures and dementia. SPECT scans are also approved for heart problems such as arterial blockage, and cancer evaluation, especially determining the extent of metastasis.
Appeal type: Experimental/Investigational
Decision: Overturned

A 47-year-old female enrollee has requested genetic testing with the Verifi test for evaluation of her fetus for aneuploidy.  Findings:  Two physician reviewers found that per ACOG, The use of a cell free fetal DNA test should be an active, informed choice and not part of routine prenatal laboratory testing. The family history should be reviewed to determine if the patient should be offered other forms of screening or prenatal diagnosis for a particular disorder. A baseline ultrasound examination may be useful to confirm viability, a singleton gestation, gestational dating, as well as to rule out obvious anomalies. This patient meets several of the ACOG recommended criteria for prenatal fetal aneuploidy testing. Specifically, the patient is of advanced maternal age with a history of a prior pregnancy with a trisomy. Consistent with these findings, the diagnostic testing at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.
Appeal type: Experimental/Investigational
Decision: Overturned

A 58-year-old male enrollee requested iStent for medical treatment of his medical condition.   Findings:  Three physician reviewers found that current medical evidence supports the services in this clinical setting.  There is sufficient support for the use of iStent to lower intraocular pressure in this patients case.  This patient was an appropriate candidate for the procedure, which had the potential to reduce the intraocular pressure and potentially reduce or eliminate the need for ocular antihypertensive medication. Other therapies have been tried, including medications, without adequate pressure control.  Therefore, the iStent was likely to have been more effective than other treatment modalities.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for H-Wave device. Findings:  The physician reviewers found that meta-analysis of the peer-reviewed literature regarding low back pain reveals multiple non-randomized or anecdotal studies/reports in the medical literature which report patients benefit from H-Wave. Also, comparative studies demonstrating a greater benefit from TENS versus other forms of passive treatment are lacking.  Overall, there is a lack of high-quality or peer-reviewed studies comparing H-Wave to standard treatment options.  In sum, H-Wave device is not likely to be more effective than other standard options for treatment of this patients medical condition. Final Result: 3 of 3 reviewers determined that the requested device is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: All three physician reviewers are board certified in physical medicine and rehabilitation with sub-specialty certification in neuromuscular medicine 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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for admission to a 60-day residential treatment center (RTC) program, or admission to a 30-day RTC program, or caregiver services. The American Association of Community Psychiatrists Level of Care Utilization System (LOCUS) provides a reliable framework for determining the appropriate level of care for adults needing mental health treatment. Using LOCUS, providers score patients on a scale of 1-5 using a six-pronged Dimensional Rating System. The six dimensions include: (1) risk of harm; (2) functional status; (3) medical, addictive and psychiatric comorbidity; (4) recovery environment (a. stressors and b. supports); (5) treatment and recovery history; and (6) engagement. The composite score is then used to determine the level of care needed. Applying the LOCUS guideline, this patient meets the criteria for the requested 60-day RTC program. The patient is at extreme risk of harm (score 5) as he engages in behaviors that endanger himself and others. The records document destructive behaviors including making Molotov cocktails. The patient has demonstrated moderate functional impairment (score 3) with inability to perform activities of daily living (ADLs). The patient has no significant comorbidities (score 1) in addition to schizophrenia. The patients recovery environment is moderately stressful (score 3) given the patients anger and aggression toward his family members. The patients recovery environment is supportive (score 2) but inadequate as it is unable to provide the requisite structure, limits, and professional input to appropriately address the patients issues. The patient has shown poor response to treatment (score 5) despite multiple admissions. The patient has been inaccessible (score 5) as he has been unable to form therapeutic working relationships with his providers. This gives the patient a composite score of 24, which is consistent with medically monitored residence based services, such as RTC. Given the severity of the patients illness, admission to a 60-day RTC program 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 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

Nature of Statutory Criteria/Case Summary:   An enrollee has requested  Nuvigil for treatment of her fatigue associated with multiple sclerosis.  The physician reviewer found that Nuvigil is widely used by MS specialists to combat MS related fatigue. These drugs enhance alertness and in some patients improve MS related fatigue. Providers that treat MS use a variety of stimulants including various amphetamines, Ritalin, and Nuvigil. While the literature is mixed, the use of Nuvigil is supported in the peer-reviewed literature. Lange and colleagues investigated the effects of modafinil on focused attention, motor function and motor excitability in patients MS and fatigue. The authors found that compared to placebo, modafinil improved fatigue, focused attention and dexterity and enhanced motor cortex excitability. The authors concluded that modafinil may be helpful in MS patients with fatigue to improve cognitive and motor abilities. Given that the patient has tried and failed multiple other stimulants, Nuvigil is medically necessary in this clinical setting.   Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: The reviewer is board certified in 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential level of care services. Findings:  The physician reviewer found that due to the lengthy history of drinking and increased reports of consumption, a residentially based detoxification and preliminary introduction to chemical dependency treatment was safe, appropriate and consistent with good medical practice.  Although addiction specialty services remained indicated, the clinical documentation does not demonstrate the medical necessity of treatment in a 24-hour supervised setting.  First, the absence of significant comorbidity supported a less restrictive setting.  There was no evidence of the emergence of late alcohol withdrawal symptomatologies.  Despite the diagnoses of hypothyroidism and transaminitis, the patient was medically stable and completed the detoxification treatment uneventfully.   Upon admission for detoxification, her depression and anxiety were untreated.  However, the patient responded well to the introduction of a pro-serotonergic medication while her symptoms were not generating a psychiatric syndrome that warranted treatment in a residential setting. Second, the patient embraced recovery principles and was motivated in her quest for sobriety.  She had a safe and sober environment at home.  She had no other addictions besides alcohol.  She had no prior history of chemical dependency treatment in a less restrictive setting, such as anti-craving medication, community programming, outpatient specialty care, intensive outpatient services or partial hospitalization.  Modern psychiatric practice favors treatment in the community as outcome measures and therapeutic gains are optimized in this environment. There was no evidence to suggest that comprehensive, evidence-based services provided in a less restrictive treatment setting would have been insufficient or inadequate at the time.  All told, residential level of care services during the dates of service in question were not medically indicated 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 physician 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 62-year-old male enrollee has requested Voltaren 1% gel for the treatment of his back pain. Findings:  The physician reviewer found that the submitted medical records do not reveal any apparent adverse reactions to oral NSAIDs. Nor is there objective documentation of any contraindications to oral medications. It is not apparent that this patient has tried other therapies beyond NSAIDs. There is no clear scientific evidence of superior efficacy of Voltaren 1% gel versus other NSAID therapies. Voltaren 1% gel does offer a clinical advantage in some cases in that it can deliver NSAID therapy to osteoarthritic joints with less systemic uptake than oral NSAIDs, as the medication is not delivered via the gastrointestinal tract. Although Voltaren 1% gel may be indicated for some patients with osteoarthritis in the joints, the drug has not been studied in conditions of the spine and is thus not indicated for this patients pain complaints.  Moreover, this patient has no clear contraindication to oral NSAIDs.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested applied behavior analysis (ABA) services for treatment of his autism.  Findings: Two physician reviewers found that there is sufficient support for the requested services in this patients case.  The requested ABA services are medically necessary for modification of this patients autism spectrum disorder.  The requested number of hours of ABA services are well within the guidelines of best medical practice.  At issue is the notion that plasticity in the developing brain, albeit a brain with underlying neurologic disease, exists and can be utilized to improve overall neurologic health.  ABA therapy can be used to help induce brain plasticity, with the ultimate goal of retraining neural circuitry not compromised by the underlying pathogenetic processes that give rise to the developmental delays and social disconnection associated with autism spectrum disorder.  In sum, the requested services ABA services are medically indicated for the treatment of this patient.  Final Result: Two reviewers 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:  One reviewer is actively practicing and is board certified in neurology with special qualification in child neurology.  One reviewer is actively practicing and is board certified in neurology with special qualification in child neurology.  One reviewer is actively practicing and is board certified in pediatrics with sub-specialty certification in developmental-behavioral pediatrics.  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: Overturned

A 52-year-old female enrollee has requested ziv-aflibercept (Zaltrap) for treatment of her recurrent ovarian cancer.  Findings:  Two physician reviewers found that this is a heavily treated patient with recurrent ovarian cancer. She has already received numerous chemotherapy off-label regimens since she has exhausted the standard options (National Institutes of Health). Zaltrap has been used off-label in ovarian cancer. There are phase II data that demonstrate efficacy with limited toxicity especially in the resolution of malignancy ascites. Based on this medical evidence, it is medically appropriate to treat this patient with Zaltrap. Thus, the Zaltrap provided from the time period specified and forward was and is likely to be more beneficial for treatment of this patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for regimen of Keytruda (pembrolizumab), Taxol (paclitaxel), and carboplatin.According the National Comprehensive Cancer Network (NCCN) guidelines, this patient should be treated as if he has a non-small cell lung cancer of adenocarcinoma subtype. Per the NCCN guidelines, based on staging, lack of driver mutations, and PD-L1 status, the treatment of choice would be carboplatin, pemetrexed, and pembrolizumab. Additionally, Gandhi and colleagues conclude, In patients with previously untreated metastatic non-squamous non-small-cell lung cancer without estimated glomerular filtration rate (EGFR) or anaplastic lymphoma kinase (ALK) mutations, the addition of pembrolizumab to standard chemotherapy of pemetrexed and a platinum-based drug resulted in significantly longer overall survival and progression-free survival than chemotherapy alone. In this case, this patient has an adenocarcinoma presumed of lung primary. Per the NCCN guidelines, the requested regimen is not indicated. Therefore, the requested regimen of Keytruda (pembrolizumab), Taxol (paclitaxel), and carboplatin is not medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the requested regimen 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 medical 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: Upheld

Findings:  The physician reviewer found that The patient has requested reimbursement and prospective authorization and coverage for skilled nursing facility services. Prusynski and colleagues report that while there is moderate evidence that higher intensity therapy was associated with higher rates of community discharge and shorter lengths of stay there was low evidence indicating that higher intensity therapy is associated with improvements in function. In this case, the records do not document that the patient requires skilled nursing or therapy services. Such services typically refer to treatment regimens that start in the hospital and need to be continued such as complex medication schedules, wound care, or rehabilitation. In this case, the patient had a stable tracheostomy and enteral feedings, and did not have complex wound care needs. The patients functional level did not require the skills of a professional therapist on an inpatient basis. The records noted extensive prior therapy training. Given that the patient does not have ongoing skilled nursing needs, such as professional physical or occupational therapy, that can only be administered in a skilled nursing facility and as the care can be safely and effectively met at a lower level, the services at issue were not and are not medically indicated. Therefore, skilled nursing facility services were not and are not medically necessary for the treatment of this patient.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.