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

The parent of a male enrollee requested residential treatment services for medical treatment of the enrollees behavioral health conditions.  Findings:  The physician reviewer found that in reviewing the clinical documentation, the patient had not consolidated the treatment gains needed to succeed in a less restrictive setting and discharge at an early date would have been premature.  He expressed intent to resume cannabis use and demonstrated self-centered and attention-seeking behavior.  This patient was likely to have promptly relapsed in the absence of the residential program services if he had been discharged.  The evidence-based services were delivered in accordance with an individualized treatment plan aimed at successfully transitioning the patient to a less restrictive setting.  The services were reasonably expected to improve his condition and prevent a more serious episode of illness.  All told, residential treatment services were medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Overturned

A 57-year-old male enrollee has requested CyberKnife surgery for the treatment of his colorectal cancer with liver metastases. Findings:  Three physician reviewers found that CyberKnife use would be controversial if it was used as an alternative to surgical resection or some other proven first-line intervention. That is not the case here. The use of CyberKnife is palliative in a patient who has exhausted the standard of care and the current literature shows it to have low toxicity. The use of CyberKnife therapy for this patient with liver metastases seems medically reasonable and appropriate.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: A 27-year-old female enrollee has requested reimbursement for transcranial magnetic stimulation (TMS) services.  Findings:  The physician reviewer found that the medical literature, Lusicic and colleagues reported that evidence for repetitive TMS in patients with OCD is accumulating and informing further developments in the field of neurostimulation. Further, Jaafari and colleagues noted that two random controlled studies demonstrated benefit with TMS for patients with OCD in patients resistant to first-line conservative treatment. The records provided for review indicate that this patient has OCD and has failed first-line conservative care. Given these findings, the TMS services provided were medically necessary for treatment of this patients OCD. Final Result: The reviewer determined that the services at issue were 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 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: Experimental/Investigational
Decision: Upheld

A 50-year-old male has requested coverage for a past coronary computed tomography (CT) angiography with 3D imaging for evaluation of his atypical chest pain with abnormal stress treadmill.   Findings:  Two physician reviewers found that the patient has a history of hyperlipidemia, obesity, and psoriasis. He presented with non-exertional chest pressure and left arm pain associated with dyspnea. An exercise stress test did not provoke chest discomfort but he developed 1 to 1.6mm horizontal inferolateral ST depression at peak exercise that became downsloping in recovery. Invasive coronary angiography was recommended, but the patient was not agreeable to that procedure. Coronary computed tomography (CT) angiography was then performed and revealed a left ventricular ejection fraction of 0.68 as well as 50% stenosis of the mid left anterior descending coronary artery. At a follow-up visit, conventional coronary angiography was again recommended.  Based on the records provided, the patient presents with some coronary risk, atypical chest discomfort and ischemic appearing ST depression on stress testing. In this circumstance the likelihood of significant obstructive coronary disease is at least moderate-to-high such that if an assessment of coronary anatomy were thought to be medically necessary then conventional coronary angiography would be preferred and considered standard accepted practice in the medical community. The patients cardiologist also recommended conventional coronary angiography. Coronary CT angiography has been demonstrated to be less sensitive in diagnosing obstructive coronary disease and less accurate in quantifying coronary stenosis compared to conventional angiography (Miller, et al). In general, coronary CT angiography generally is not recommended in clinical situations of moderate to high likelihood of disease (Mark, et al). Also conventional coronary angiography offers the advantage of being able to intervene using percutaneous revascularization during the same procedure, if medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Subsys for treatment of his medical condition.  Findings:  The physician reviewer found that based on the documentation submitted for review, the medical necessity for Subsys has not been established. According to the documentation submitted for review, the patient has been treated with multiple high dose opioid medications. There is a lack of documentation demonstrating improved function or attempted weaning of these medications. In addition, the patient has non-malignant chronic pain, which will often worsen or recur as a result of opioid rebound. Current standard of care for chronic pain is treatment in a multidisciplinary pain management practice to include physical therapy, massage therapy, cognitive behavioral therapy, and injections to help reduce pain.  Baron and McDonald reported that high dose and short acting opiates might contribute to pain sensitization via opioid-induced hyperalgesia, decreasing patient pain threshold and potentially masking resolution of a preexisting pain condition. In this retrospective study, the majority of patients undergoing detoxification of high dose opiates for chronic pain reported a significant decrease in pain at the end of the study, further supporting the theory of opioid-induced hyperalgesia. Given the above, the requested medication is not medically necessary for treatment of the patients medical condition.  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 anesthesiology with sub-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

A 26-year-old male enrollee requested immediate neuropsychiatry assessment to determine whether his behavior is attributable to his brain injury, psychiatric condition or combination of both; an assessment to make a differential diagnosis of his brain condition and psychiatric condition; learning and coping skills so he can have a productive life; an assessment of his psychological defects and his psychiatric/psychological condition; and intensive individual psychiatric therapy (not group therapy) with cognitive behavioral dialectical therapy, with any other therapies a neuropsychiatrist can provide for medical evaluation of his late effects of anoxic brain injury.  Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of a portion of the requested services.  The neuropsychological evaluation encouraged the patient to seek community-based specialty resources.  As such, a routine neuropsychiatric assessment is indicated.  However, as the patient is not experiencing an acute psychiatric syndrome or demonstrating imminent safety concerns, an immediate or emergent evaluation is not medically necessary.  The requested assessment to make a differential diagnosis of the patients brain condition and psychiatric condition is not medically indicated.  A neuropsychiatric assessment will provide the differential diagnosis of the patients brain and psychiatric conditions, and a separate assessment is not necessary.  With regards to the requested learning and coping skills, this patient has been involved in comprehensive physical medicine and rehabilitation services and outpatient psychotherapy.  Further, he has been encouraged to participate in mental health services at a higher level of care to address clinical needs related to enhancement of coping skills and optimization of learning strategies.  Thus, unless these particular services are recommended by the neuropsychiatric assessment, they are not medically necessary.   Per the submitted documentation, the requested assessment of this patients psychological defects and his psychiatric/psychological condition is not medically necessary.  Additionally, the requested intensive individual psychiatric therapy (not group therapy) with cognitive behavioral and dialectical therapy, with any other therapies a neuropsychiatrist can provide is not medically necessary.  An individualized, patient-centric treatment plan is a key element for clinical success.  If the treatment team determines that specific evidence-based psychotherapies are indicated, they should be made available to the patient.  However, at this time, based on the documentation provided, it is premature to specify the particular therapeutic modalities and treatment settings necessary in this patients case.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a 16-year-old male enrollee has requested authorization for growth hormone therapy for treatment of the enrollees short stature.  Findings:  The physician reviewer found that the information provided presents minimal evidence for the putative neuro-secretory defect; the patients shortest height appears to have been near the 10th percentile, and he is already beyond the height limit set by the FDA for idiopathic short stature.
Appeal type: Medical Necessity
Decision: Upheld

A 35-year-old female enrollee has requested authorization and coverage for laparoscopic banding bariatric surgery.  Findings:  The physician reviewer found that based on review of the available records, the patient has a history of obesity with a BMI between 32 and 36 over the last 4 years. The patients current weight is 202 pounds with a BMI of 35. The patient reports a variety of medical attempts at weight loss with mild temporary relief with weight regain. She reports medical conditions including asthma, allergies, fibromyalgia, and pituitary adenoma with underlying psychiatric issues of generalized depression, anxiety, and bipolar disorder with mania. The patient has requested services of laparoscopic gastric banding which was denied due to lack of co-morbid medical diseases such as type II diabetes mellitus, hypertension, coronary artery disease, or obstructive sleep apnea, as required by the generally accepted guidelines for bariatric surgery in patients with a BMI between 35 and 40. The patient has fluctuated between obese and morbidly obese, but does not have any evidence of significant co-morbid conditions that would justify bariatric surgery. As no co-morbid disease is documented, the patient would unlikely achieve a medical benefit to bariatric surgery. For these reasons, the requested surgery is not medically necessary for management of this patients medical conditions.
Appeal type: Medical Necessity
Decision: Overturned

A 67-year-old male enrollee requested intensity modulated proton radiation therapy for medical treatment of his adenoid cystic carcinoma. Findings:  The physician reviewer found the patient has locally advanced adenoid cystic carcinoma with base of skull involvement as shown on imaging.  In order to eradicate the cancer radical radiation treatment is required. This is a complex case with skull base involvement, due to the close proximity of normal structures. In this case, these structures include the temporal lobe, optic nerve, and brain stem. Unfortunately, the radical radiation doses required to eradicate the cancer exceed the tolerance doses of these normal structures.  Adenoid cystic carcinoma of the head and neck with skull base involvement is a rare condition.  Therefore, treatment recommendations have to be based on retrospective case series. Based on the peer-reviewed literature and ASTRO model policy, intensity modulated proton radiation therapy in comparison with intensity modulated radiation therapy with photon is more likely to achieve disease control with less treatment related toxicity. Thus, the requested services are medically necessary for treatment this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 51-year-old female enrollee has requested residential treatment center (RTC) services for treatment of her depression and anxiety.  Findings:  The physician reviewer found that the medical records provided for review document that by the date indicated, the patient was no longer suicidal. She was working through feelings of resentment, anger, and grief over the massive disruption in the relationship with her family. The patient was no longer expressing feelings of wishing to engage in self harm. She had already been stabilized on her medication regimen and there were no further significant adjustments. The records indicate the patient could have been safely and adequately treated at a lower level of care. Therefore, the RTC services provided from the time frame specified were not medically necessary for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

A 51-year-old female enrollee requested a brain positron emission tomography (PET) scan for medical evaluation of her neurodegenerative condition.   Findings:  Two physician reviewers found that in the medical literature, Claassen and colleagues reported that PET and 3-dimensional stereotactic surface projection  provide a useful diagnostic method to support a clinical diagnosis of primary lateral sclerosis. Studies with PET demonstrate predominant primary motor strip involvement. This pattern is illustrative of a stripe of hypometabolism. Thus, the literature does support the use of the requested PET for the evaluation of primary lateral sclerosis, looking for a stripe of hypometabolism. All told, the requested PET scan would be helpful to exclude primary lateral sclerosis in this patients condition.
Appeal type: Experimental/Investigational
Decision: Overturned

A 32-year-old female enrollee has requested Botox injections for the treatment of her migraine headaches. Findings:  Two physician reviewers found that this patient has chronic migraine with heavy use of acute therapy, frequent emergency room visits, and high degree of disability. She has seen multiple neurologists and failed over 5 preventive therapies, including all of the FDA approved drugs for migraine prevention. The phase II Botox study (Mathew, et al.) included exactly this type of patient, and showed significant improvement in many of the secondary endpoints. The phase III studies are completed and a preliminary announcement indicated they met the primary endpoint of migraine reduction in chronic migraine. As this patient has already been given adequate trials of usual treatment, investigational treatment with an effective agent such as Botox is necessary.
Appeal type: Medical Necessity
Decision: Upheld

A 36-year-old male enrollee has requested an MRI of the lumbar spine for an evaluation of his back pain. Findings:  The physician reviewer found that this patient clearly does not meet the established guidelines for MR imaging of the lumbar spine. There are no significant neurological deficits and x-rays show degenerative disc disease and mild lumbar stenosis. He has not yet had a trial of physical therapy.
Appeal type: Medical Necessity
Decision: Upheld

A 55-year-old female enrollee requested authorization and coverage of an increase in her monthly Zomig prescription. The Health Plan denied the request indicating that an increase in the enrollees monthly Zomig prescription is not medically necessary for treatment of the enrollees migraine headaches.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested increase in the enrollees monthly prescription of Zomig is not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested Harvoni for treatment of his hepatitis C virus (HCV). Findings:  Two physician reviewers found that according to the American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) guidelines Successful hepatitis C treatment results in sustained virologic response (SVR), which is tantamount to virologic cure, and as such, is expected to benefit nearly all chronically infected persons. Evidence clearly supports treatment in all HCV-infected persons, except those with limited life expectancy (less than 12 months) due to non-liver-related comorbid conditions. The goal of treatment of HCV-infected persons is to reduce all-cause mortality and liver-related health adverse consequences, including end-stage liver disease and hepatocellular carcinoma, by the achievement of virologic cure as evidenced by an SVR. In this case, the patient has cirrhosis due to ongoing HCV infection. Therefore, Harvoni is medically necessary to prevent further progression of cirrhosis to decompensated state due to ongoing HCV infection and prevent potential complications of advanced liver disease, long-term such as liver failure requiring liver transplant, and hepatocellular carcinoma. Final Result: Two 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: Two reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology and are actively practicing. A third reviewer is board certified in gastroenterology and is 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

The patients parent has requested reimbursement for residential treatment center (RTC) services.  The American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists Child and Adolescent Level of Care Utilization System (CALOCUS) provides a reliable framework for determining the appropriate level of care for adolescents needing mental health treatment. Using CALOCUS, 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) developmental, medical, substance use 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. This gives the patient a composite score which is consistent with high intensity community based services. Given these findings, the RTC services were medically necessary for treatment of this patient. Final Result: The reviewer determined that the services at issue were 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 with subspecialty certification 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 a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Hyaluronan (Euflexxa) injections in the left knee. The submitted documentation supports the medical necessity of the requested services. The current literature continues to support the use of viscosupplementation for osteoarthritis of the knees. There is good evidence that intraarticular hyaluronic acid injections reduce pain and increase function in knee osteoarthritis, and the benefits are long-lasting as compared with intraarticular corticosteroids. Evidence from real-life studies of repeat courses of intraarticular hyaluronic acid demonstrates an improvement in pain or function lasting up to 40 months, a reduction in use of concomitant analgesia by up to 50%, and suggests that there may be a delay in the need for total knee replacement of around 2 years. The reviewed medical literature also includes a systematic review of overlapping meta-analyses comparing viscosupplementation with other nonoperative treatment modalities for knee osteoarthritis. This review found that that the current highest level of evidence suggests that intraarticular hyaluronic acid is a viable option for knee osteoarthritis and that its use results in improvements in knee pain and function that can persist for up to 26 weeks. Viscosupplementation has a good safety profile, and its use should be considered in patients with knee osteoarthritis. There is sufficient support for the requested services in this clinical setting. Therefore, Hyaluronan (Euflexxa) injections in the left knee 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 orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a 20-year-old female enrollee has requested a referral to a pediatric gastroenterologist for suspected fatty liver disease and G-tube care.  Findings:  The physician reviewer found that the patient does not require ongoing care with her pediatric gastroenterologist. The Health Plan indicates the patients primary care physician can request a referral to a GI specialist if needed. No evidence has been provided that the patient is unable to receive appropriate care from another gastroenterologist on an as needed basis or that the nature of her condition requires that she continue to be followed by her pediatric gastroenterologist.