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

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement for intensive outpatient program (IOP) services. Findings:  The physician reviewer found that the Child and Adolescent Level of Care Utilization System (CALOCUS) criteria is used to objectively determine if the patient meets criteria for length of stay. This is an accepted, national standard for determining the appropriate level of care for children and adolescents. According to CALOCUS criteria, the patients risk of harm is scored a 2, which correlates to some risk of harm.  The patient was successfully detoxed from substances and did not present with acute withdrawal symptoms. The patients functional status is scored a 3, moderate functional impairment. The patient was expelled from two to three schools. The patient was failing his classes.  The patient had conflicted relationships with his parents. The patients recent gains have been achieved in a structured setting. The patients comorbidity is scored a 3, significant comorbidity. The patient has a comorbidity of sedative, hypnotic, anxiolytic use disorder, major depressive disorder, and generalized anxiety disorder. The patient did not have any medical problems, which required 24 hour monitoring. The patients recovery environment is scored a 3 which correlates to moderately stressful environment. The record notes that he has had conflicts with family members over his substance use, which has caused a moderately stressful environment. His environmental support is scored a 2, supportive environment.  The patient has supportive parents who are willing to participate in treatment if asked to do so. The patients resiliency is scored a 3, equivocal response to treatment. The patient has improved in his RTC and IOP treatments. However, recovery has been maintained for moderate periods of time in structured settings. The patients acceptance and engagement is scored a 2, constructive. The patient is cooperative with staff. The patient seems to be passively participating in treatment. According to CALOCUS, the patients composite score is 18. Therefore, based on these criteria, the patient did meet criteria for IOP during the dates of service in dispute. As such, intensive outpatient program services were medically necessary for the 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 expertise 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Xenon-enhanced computed tomography (CT) cerebral blood flow study. The International Headache Society (IHS) defines post-traumatic headache as a secondary headache attributed to trauma or injury to the head that develops within seven days following the trauma. Acute post-traumatic headache is defined when the headache resolves within three months after traumatic brain injury (TBI), whereas persistent post-traumatic headache is characterized by headache lasting longer than three months. Patients with a history of TBI and new headache complaints require additional imaging to rule out other causes. Any acute change in neurologic status or sudden change in frequency and intensity of headache may also warrant additional imaging. Xenon-enhanced CT reveals blood flow to various regions of the brain. Xenon-enhanced CT has been shown to have utility in occlusive vascular disease, ischemic and hemorrhagic stroke, subarachnoid hemorrhage, trauma, hydrocephalus, epilepsy, and tumor. In this case, the patient presents with post-traumatic headaches. The current studies and recommendations have not demonstrated the utility of Xenon-enhanced CT cerebral blood flow study in the work-up of patients with post-traumatic headaches. Accordingly, the requested Xenon-enhanced CT cerebral blood flow study is not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Findings:  Three of the three physician reviewers found the requested Xenon-enhanced CT cerebral blood flow study is not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested services are 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 reviewer 1 is board certified in neurology with subspecialty certification in neuromuscular medicine and is actively practicing. Physician reviewer 2 is board certified in neurology with subspecialty certification in vascular neurology and is actively practicing. Physician reviewer 3 is board certified in neurology and is 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollees parent has requested authorization and coverage for Korlym 300 mg tablet (3 times daily). In a systematic review of the literature on the role of mifepristone in the management of meningiomas, Cossu and colleagues concluded that no clear evidence existed to recommend mifepristone in inoperable meningiomas. The authors noted that while preliminary encouraging results were found in diffuse meningiomatosis, further multicenter placebo-controlled trials were required. Apra and colleagues report that current standard of care in the treatment of meningioma includes observation, surgery, and radiotherapy. The authors note that systematic therapies are not effective in general but that there are several ongoing clinical trials. Given that current medical literature does not recommend the use of mifepristone in the treatment of sella meningioma, the requested medication is investigational. Therefore, Korlym 300 mg tablet (3 times daily) is not likely to be more beneficial for the treatment of the patients condition than any available standard therapy.Findings:  Three of the three physician reviewers found the requested Korlym 300 mg tablet (3 times daily) is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested medication 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: Physician reviewer 1 is board certified in internal medicine with sub-specialty certifications in medical oncology and hematology and is actively practicing. Physician reviewers 2 and 3 are board certified in internal medicine with sub-specialty certification in medical oncology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

ature of Statutory Criteria/Case Summary: An enrollee has requested OxyContin for treatment of her sarcoidosis.  Findings: The physician reviewer found that chronic pain that is unable to be cured can be considered palliative in nature and treatment. The step wise World Health Organization (WHO) ladder for pain relief is considered the reasonable approach to pain control in the palliative setting. In this patient, the submitted records do not indicate that all non-opioid treatment options have been utilized nor does the documentation indicate an optimization of all non-opioid medications.  Rather, quite large doses of opioids are being used despite research to show the dangers of a high dose and its lack of efficacy as it impacts quality of life.  The submitted records do not show that this patient has participated in behavior therapy despite much research supporting its use. The records reflect that tolerance has taken place as indicated by the use of narcotics and dose escalation which differs from the original plan by the physician who started the OxyContin.  Dose escalation is not a long term plan but a short term plan for the treatment of tolerance. The addition of more pure mu agonists will, for a short while, take care of the symptoms of mu agonist saturation; however, down regulation will transpire and then the patient is only back to where they started in terms of their pain perception. Studies reveal that such patients are worse off since they now have a much higher opioid tolerance level.  Additionally, there are other non-pure mu agonists that have long lasting duration that do not appear to have been considered based on the records provided. Further, there is no plan in place to monitor this patient with the medications both historically and currently. The documentation does not discuss other standard sarcoidosis treatments since the original notation.  Finally, multiple minimal requirements for opioid prescribing have not been met and the need to use them as the primary treatment strategy for pain has not been established. For all these reasons, the request of OxyContin 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-specialty certification in pain medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for robotic-assisted total laparoscopic hysterectomy. The Health Plan has denied this request indicating that the requested services are not medically necessary for treatment of the patients endometriosis and uterine fibroids. The submitted documentation of the patients medical needs does not support the medical necessity of the requested services. The patient does have a well-established history of pelvic pain. However, the patient has never been treated with medical or conservative surgical management. The patient has not had a diagnostic laparoscopy and does not have a tissue diagnosis of endometriosis. The patients ultrasound shows a fairly normal sized uterus and it does not show large or rapidly growing fibroids, when compared to the ultrasound in 2012. Under these circumstances, it is reasonable to trial conservative medical and/or surgical management prior to proceeding with a hysterectomy. Therefore, a robotic-assisted total laparoscopic hysterectomy is medically necessary for the 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 obstetrics and gynecology 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: The parent of an enrollee has requested authorization and coverage for Saizen 8.8 mg vial. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication. This patients height is not more than two standard deviations below the mean for age and gender. The records do not document evidence of fall-off in growth velocity prior to initiation of growth hormone therapy, pre-treatment growth factors were normal, weight for height ratio is low, and there are no known morphological age abnormalities of the pituitary gland. Thus, the patient does not meet standard criteria for growth hormone deficiency. Furthermore, the patients adult predicted height is not short enough at this time to consider empiric growth hormone therapy for treatment of idiopathic short stature. The most likely cause of the patients mild delay in bone age is constitutional delay, which may be associated with poor weight gain, as well. The current medical evidence does not support the requested medication in this clinical setting. All told, Saizen 8.8 mg vial is not medically necessary for the treatment of this patient. 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 pediatrics with sub-specialty certification in pediatric endocrinology 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 hospital stay .  Findings:  The physician reviewer found that the documentation provided fails to demonstrate the medical necessity for the services at issue. Several factors are considered when determining whether a patient is appropriate for transfer to a Long Term Acute Care Hospital (LTACH ) for respiratory care and weaning. First, the acute illness should be resolved. Second, the patient should not be dyspneic or hypoxemic during mechanical ventilation. Third, patients should have a stable airway and route to receive nutrition, which usually consists of a tracheostomy and enteral feeding tube.  In this case, the patient was responding to treatment for aspiration pneumonia with associated respiratory failure.  He stabilized and improved slowly but was still not stable enough to have surgery.  The patient had stable vital signs of 133/77, 98% oxygen saturation on an oxygen mask.  The repeat chest x-ray was improved, the laboratory results showed improvement in systemic inflammation and infection.  The patient was being monitored on telemetry and was receiving parental antibiotics and scheduled breathing treatments.  The patient was taking nutrition by mouth.  The surgical repair of the hip had been postponed due to his respiratory status, which had stabilized but not enough for surgery. He was clinically improving and diagnostic studies showed that the acute illness was resolved.  The patient continued to have hypoxic episodes when trying to wean off of supplemental oxygen.  The transfer to a LTACH was appropriate and the patient was stable for a lower level of care.  Therefore continued in-patient hospital stay was not medically necessary as the patient could have safely been treated at a lower level of care.  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 internal 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: Overturned

A 58-year-old female is has requested transcranial magnetic stimulation (TMS) therapy for treatment of her major depression.  Findings:  Two physician reviewers found that as reported by Janicak and colleagues, the use of TMS for that treatment of major depressive disorder (MDD) is supported in the scientific literature with favorable assessments of its safety and effectiveness. Consistent with this, Demitrack and Thase noted that the value of TMS in the treatment of MDD is widely recognized as a clinically significant treatment option in patients resistant to other treatments. Thus, the TMS is currently within the standard of care in the treatment of depression in well selected patients and is used at leading academic institutions as well as in the private practice environment. With regard to this patient, multiple attempts at treatment with antidepressants and psychotherapy. These treatment modalities were tried and were either discontinued due to side effects or were insufficient to produce an adequate clinical response although administered in adequate dosages and for sufficient durations. Therefore, in the presence of continuing depression, it was reasonable to provide the patient with a trial of therapy with TMS, given the published support for its safety and efficacy in the treatment of patients with refractory MDD. Accordingly, the use of TMS in the management of this patients condition should not be considered investigational and was likely to be more beneficial than standard alternatives.
Appeal type: Medical Necessity
Decision: Overturned

The patient has requested authorization and coverage for Synvisc-One injection in the right knee. Per the medical literature, although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. The current evidence is limited, and guidelines indicate that the evidence is not conclusive. In light of the foregoing, viscosupplementation can only be recommended in individuals with a history of lasting benefit from prior injections, and in carefully selected cases where everything else has been tried, and the options are limited. In this case, the patient has a history of chronic right knee pain due to osteoarthritis. The records show the patient had a prior excellent response to a Synvisc-One injection to the right knee, providing pain relief and functional improvement. The patient has tried and failed other conservative measures, including corticosteroid injections, which are no longer effective, with the alternative being a total knee arthroplasty. Given the patients limited options and based on the current medical literature, the requested service is medically indicated. Therefore, Synvisc-One injection in the right knee is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested service 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 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: Experimental/Investigational
Decision: Overturned

A 56-year-old female enrollee requested authorization and coverage of stem cell transplant (high dose chemotherapy with stem cell rescue) for the treatment of cancer and end-stage renal failure.  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 stem cell transplant (high dose chemotherapy with stem cell rescue) is likely to be more beneficial for treatment of the enrollees cancer and end-stage renal failure than any available standard therapy.  Because all three physician reviewers concluded that the requested treatment is likely to be more beneficial for treatment of the enrollees medical condition than any available standard therapy, the review organization overturned the health plans denial.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 14-year-old female with an 18q chromosomal deletion and associated nystagmus, head tilt, tremors, and mild developmental delay.  She has been receiving speech and language therapy since 2002. An IEP is provided which documents she is receiving 60 minutes of speech therapy per session through school.  No speech therapy reports or testing from the school are provided to document gains, but the IEP team meeting report recommends continued speech therapy. The patient has also been receiving private speech and language therapy and her provider recommends continued treatment, but the frequency and duration are not specified.  The parents request for on-going speech therapy was denied by the Health Plan citing a lack of medical necessity. In evaluating the need for continuing speech therapy, a demonstration of functional gain is essential to a determination of medical necessity.  A review of the progress reports from the private speech therapy shows limited and inconsistent documentation of goals.  The long-term goals outlined in the January 2006 progress report are not reflected in the goals outlined in the May 2006 report. Thus, it is impossible to determine functional gains from these reports. Although the standardized testing indicates improved scores, the therapy reports do not demonstrate goals and/or functional gains that coordinate with the testing results.  Additionally, the patient is receiving appropriate speech therapy through the school system that is part of an overall educational plan. The added private therapy is a duplication of services. The patients condition is long-standing and involves developmental delay; a fully integrated plan is required to maximize academic success.  In most cases medically based therapy is provided due to an illness, injury of congenital abnormality and is meant to be restorative and of limited duration. In this case, the speech and language goals are long-term and better managed by the educational system.  Based upon the information set forth above, I have determined the requested therapy is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.