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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for transcranial magnetic stimulation (TMS) for treatment of the enrollees major depressive disorder. Findings:  The physician reviewer found that TMS is a non-invasive brain stimulating procedure utilized in the treatment of major depressive disorder. The procedure is approved by the U.S. Food and Drug Administration. TMS is well tolerated with fewer barriers than electroconvulsive therapy. Further, the American Psychiatric Association (APA) recommends TMS for the acute phase treatment of major depressive disorder after failure of at least one antidepressant trial. Considering the medical records submitted for review, endorsement from the APA and support in the peer-reviewed literature base, TMS is a safe, appropriate treatment consistent with good medical practice. The therapy would be reasonably expected to improve the patients condition and prevent a more serious episode of illness. As such, the request for TMS is 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 psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The parent of the enrollee is requesting authorization and coverage for 15 minutes per week of sensory integration therapy services and 30 minutes per week of occupational therapy services. The enrollee has a diagnosis of autism spectrum disorder.  The enrollees occupational therapy evaluation described functional impairments, such as the enrollee becomes upset around transitions, spins until he falls, wakes for four hours during the night, and uses a fork independently but will not use a spoon. The goals addressing function include family identification of three to five strategies to improve self-regulation, the enrollee will sleep through the night, four to seven nights per week, and the enrollee will scoop food with a spoon and feed himself without spillage. Literature indicates sensory information forms the building blocks for higher-order social and cognitive functions, and sensory problems are considered a core symptom of autism spectrum disorder. Studies showed the use of Ayres Sensory Integration can be considered an evidence-based practice for children with autism between the ages of four and twelve. The Autism Science Foundation indicates occupational therapy is often used as a treatment for sensory integration issues in those with autism spectrum disorder.  It is used to improve skills that involve fine-motor movements, such as dressing, using utensils, cutting with scissors, and writing. Occupational therapy works to improve the individuals ability to participate fully in daily activities. Occupational therapy for young children focuses on improving sensory integration and sensorimotor issues.Final Result: The reviewer determined that the requested services are medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in child and adolescent 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 54-year-old female enrollee has requested for a blepharoplasty for treatment of her eyelid ptosis. Findings:  The physician reviewer found that based on the patients significant visual field defect and the submitted photographic evidence, she satisfied medical necessity criteria for functional blepharoplasty.
Appeal type: Medical Necessity
Decision: Overturned

A 56-year-old female enrollee has requested intensity modulated radiation therapy (IMRT) for treatment of her stage III endometrial cancer.  Findings:  The physician reviewer found that review of the submitted documentation demonstrates the medical necessity of the therapy at issue. Given the significant amount of toxicity with concurrent chemotherapy and pelvic three-dimensional conformal radiation therapy (3DCRT), it is appropriate to seek less toxic ways to deliver radiotherapy. The typical dose delivered for whole pelvic radiotherapy is above the dose tolerance for both small bowel and bone marrow. The medical literature includes studies that have demonstrated that IMRT had improved target coverage versus 3DCRT (Bouchard et al). Jhingran and colleagues reported a 28% rate of grade 2+ bowel toxicity compared to a historical rate of 40% with 3DCRT. Furthermore, the safety and efficacy of pelvic IMRT has been supported by multiple medical studies. For the reasons set forth above, IMRT was medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested a 12-week course of Harvoni for treatment of his hepatitis C.  Findings:  Three physician reviewers found that the submitted documentation supports the medical necessity of the requested medication.  The patient has advanced disease.  The records do not document contraindications to treatment, and he is motivated to be treated.  Based on the information submitted for review, this patient appears to be a high priority individual for treatment with Harvoni.  All told, the requested 12-week course of Harvoni is medically indicated for the treatment of this patient.  Final Result: Three reviewers determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: The three 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: Medical Necessity
Decision: Overturned

A forty-one year-old male with glioblastoma multiforme of the right parietal lobe is requesting continued out-of-network neuro-oncology care.Reviewers Findings:  The reviewing physician found that the patients continuity of care would be compromised by transfer from the out-of-network to the in-network facility at this point in the clinical course.  The Health Plan denial was overturned.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for residential rehabilitation for treatment of the enrollees behavioral health conditions.Findings:  The physician reviewer found that by report, the patient had difficulty maintaining sobriety on his own.  He was not a danger to himself or others, and was not manic.  He showed no signs of psychosis.  He was medically stable.  In 2016, he had failed multiple outpatient detoxification attempts.  His motivation was questionable, and he was in need of education and assistance in learning coping skills to maintain sobriety.  His relapse risk was high, and he had been authorized to receive care at transitional residential treatment.  However, the patient opted for the day treatment program, at which he did quite well, successfully graduating.  He developed motivation and received education regarding relapse prevention, and at that point he could have continued his recovery at an outpatient level of care with community support such as a 12-step program with a sponsor.  The records do not provide a rationale for the contention that he would have required the level of care or services, which was a dual diagnosis facility; either prior to starting the day treatment program or after graduation. Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 36-year-old female enrollee has requested for gastric bypass surgery for treatment of her morbid obesity. Findings:  The physician reviewer found that there is evidence that shows a far better outcome with management of the co-morbidity of diabetes with weight loss surgical procedures (metabolic surgery) than any of the medical regimens available for the treatment of diabetes. (Sjostrom, et al.) Further attempts at non-surgical weight loss are not likely to be effective for this patient.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 3-year-old male enrollee has requested skilled nursing care for treatment of the enrollees seizure disorder. Findings:  The physician reviewer found that it is clear that continuous observation is necessary for this patient to prevent aspiration, pneumonia, intractable seizures, and respiratory distress possibly progressing to respiratory failure. To manage his condition the services of a skilled nurse is required to recognize and treat any seizure activity with prompt intervention. This type of care is not passive in nature and requires active participation and commitment of a trained and experienced caregiver. While parents may function as skilled caregivers for a portion of the day, given the extent of this patients medical needs, the requested skilled nursing services are medically necessary and appropriate for this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Decision DX Melanoma testing for evaluation of the enrollees melanoma. Findings:  The physician reviewers found that the records do not indicate that sentinel node sampling was performed in this case.  All told, Decision DX Melanoma testing was not likely to have been of greater benefit than other methods of evaluating this patient. Final Result: All three reviewers determined that the services at issue were 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 reviewers number one, two, and three are board certified in internal medicine with sub-specialty certification in medical oncology and 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

A 19-year-old male enrollee has requested continued residential treatment program services for treatment of his polysubstance dependence and major depressive disorder. Findings:  The physician reviewer found that based on review of the available records, this patient meets continued stay requirements for inpatient rehabilitation services from the specified date and forward. The American Society of Addiction Medicine (ASAM) guidelines state the defining characteristic of residential treatment programs is that they serve patients who need safe and stable living environments in order to develop their recovery skills. The records document an intervening medical event, which was serious enough to interrupt rehabilitation, but the patient is again progressing in treatment. In addition, this patient meets continued stay criteria as he recognizes or identifies with the severity of his drug problem but there is documentation that he is progressing. All told, the RTC services provided from the specified date and forward are supported as medically necessary for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 63-year-old male enrollee has requested a computerized tomography (CT) scan of the heart for treatment of his medical condition.  Findings:  Two physician reviewers found the submitted documentation and relevant literature fails to support the services at issue. This patient is asymptomatic with some cardiac risk factors including his gender and hyperlipidemia. However, the medical literature has not demonstrated an improved outcome for asymptomatic men with risk scores below 10%. In the absence of compelling evidence that a CT scan of the heart results in greater clinical benefit compared to standard risk monitoring measures, there is inadequate scientific evidence to support the use of a CT scan of the heart in this clinical setting. Therefore, the services at issue were not likely to be more beneficial than other standard therapies.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for individual speech therapy at 30 minutes per session, twice per week for treatment of the enrollees severe language delay. Findings:  The physician reviewer found that the U.S. Preventive Services Task Force support speech therapy as an effective treatment for children with speech language delays. The study by colleagues evaluated direct speech therapy versus indirect speech therapy and found that children with mixed receptive and expressive language delay required the skills of direct one-on-one speech therapy. Group speech therapy is recommended for children with autism to address pragmatic language and social problems. In this case, the patient needs to focus on articulation and basic language skills. These skills are effectively treated in an individual one-on-one setting. However, there is a lack of medical literature demonstrating that two speech therapy sessions per week are medically necessary in this clinical setting. As such, individual speech therapy at 30 minutes per session at the frequency of one session per week is clinically indicated for this patient. Based on the clinical documentation provided for review, individual speech therapy at 30 minutes per session, once per week is medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that a portion of the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned. Credentials/Qualifications: The reviewer is board certified in pediatrics with sub-specialty certification in developmental and 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

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Harvoni for 12 weeks for treatment of her hepatitis C virus.  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 should be treated except those with limited life expectancy due to non-liver-related conditions. This applies regardless of fibrosis stage or viral load. Per guidelines, treatment-naive genotype 1 patients should be treated with Harvoni for 12 weeks. These guideline recommendations are based on multiple randomized clinical trials, and the medication is U.S. Food and Drug Administration (FDA) approved for all patients with chronic hepatitis C genotype 1 regardless of fibrosis stage. AASLD guidelines cite data showing reduced survival with delayed treatment. For these reasons, the requested treatment with Harvoni for 12 weeks is supported as medically necessary for the treatment of this patients hepatitis C infection. 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 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 authorization and coverage for a hospital bed with rails. Findings:  The physician reviewer found that a review of the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested equipment. In patients with dementia and agitation, the use of bedrails is not recommended as it has been shown that more severe injuries occur in beds with rails than beds without rails. Patients with dementia attempt to climb over the rails and sustain more severe head, back and hip injuries. Therefore, the request for a hospital bed with rails is not medically advisable or necessary as it may result in more severe injuries. Final Result: The reviewer determined that the requested equipment is 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 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 fifty-nine year-old male with episodic cluster headaches is requesting reimbursement for up to six injections of Imitrex 6mg per day as well as prospective authorization for three Imitrex 6mg injections per day.Reviewers Findings:The reviewing physician found that the use of greater than two 6mg Imitrex injections per day is not recommended, and may be unsafe.  The physician concluded that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

The care giver of a fifty-eight year-old male with advanced dementia is requesting authorization of medication management and psychiatric stabilization services.  Reviewers Findings:The reviewing physician found that the patient required frequent medication adjustments during the early part of the stay and is now responding predictably to medications administered on a as needed basis.  The reviewing physician found that the Health Plan denial should be partially overturned.
Appeal type: Medical Necessity
Decision: Upheld

A 64-year-old female enrollee has requested an ultrasound to be included with her routinely scheduled mammograms for her breast cancer screening. Findings:  The physician reviewer found that yearly mammograms are indicated for all women over the age of 40. Ultrasound of the breast is not a screening exam and is only done to evaluate a palpable mass, a finding detected on the mammogram or as a follow-up of a known lesion.  In this case, it appears the patients prior ultrasound films and reports are not on file. Without having the prior films in hand, or at least a report describing the size, exact location, and sonographic characteristics of a previously detected lesion, the radiologist cannot assess the importance, if any, of the sonographic abnormality. As such, the medical necessity of an ultrasound in conjunction with the patients routinely scheduled mammograms has not been established at this time. If the patients prior breast imaging records or at least her most recent ultrasound report are obtained, then her request for concurrent ultrasound and mammogram should be reconsidered.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for skilled nursing facility (SNF) services including physical therapy, occupational therapy and/or speech therapy. The records provided for review document that this patient has chronic, severe functional impairments that have not substantially improved despite therapy attempts in the past. Specifically, the patient has multiple insults to the brain, dementia, and hemiplegia. The patient has been in a custodial care setting for a long time. She is not functionally ambulatory and is dependent for most of her care. There is a lack of evidence to suggest that participation in physical, occupational and/or speech therapy will provide clinically meaningful functional gain. The patient has significant cognitive and physical impairments, which are not expected to improve given the severity of the insults she sustained, the duration of time that has passed since the insults were sustained, and the lack of meaningful response to the prior efforts at rehabilitation (Kua, et al.; Montero-Odasso and Speechley; Stocchetti and Zanier). More recently, she has been documented to have lower limb impairments that preclude safe standing or attempts at walking. Overall, the records fail to report any medical indications for SNF level of care nursing or therapy services. For these reasons, the requested SNF services including physical therapy, occupational therapy and speech therapy are not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested services 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 physical medicine and rehabilitation 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: Urgent Care
Decision: Overturned

A 38-year-old female enrollee has requested for an emergency room visit for treatment of her severe abdominal pain. Findings:  The physician reviewer found that the signs and symptoms that the patient presented with are consistent with a variety of diseases and disorders including appendicitis, cholecystitis/cholelithiasis, pyelonephritis/urinary tract infection, gastrointestinal bleeding, pelvic infection, and other potentially life-threatening illnesses. The patient presented for evaluation of acute abdominal pain of sufficient severity that a prudent layperson would be concerned enough to seek emergency medical evaluation immediately.