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

The parent of a 10-year-old male enrollee has requested applied behavioral analysis (ABA) therapy (72 hours per month of direct ABA therapy and 8 hours per month of supervision) for treatment of the enrollees autism.  Findings:  The physician reviewer found that in this patients case, he has been receiving extensive ABA therapy since the age of 3.  His language is limited to single words and the submitted records demonstrate the patient has made little substantive progress in social, language, or intellectual skills. While this patient has failed to demonstrate sustained and continuing improvement in the above noted areas, there are safety concerns that necessitate the continuation of ABA therapy at a reduced frequency. The submitted documentation demonstrates the patient is in constant danger of accidental injury. As such, it is medically necessary that he continue to receive ABA therapy in an attempt to allow him to develop sufficient insight to prevent accidental injury.  Safety concerns (e.g., crossing streets, avoidance of injury or trauma) necessitate ABA operant training to help prevent self-injury or accidents. Accordingly, 20 hours per month of direct ABA therapy limited to the objective of addressing safety concerns along with 2 hours of monthly supervision is medically necessary for treatment of the patients condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for IOP level of care. Findings:  The physician reviewer found that 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. With regard to risk of harm, the records support a score of 3. The patient has a risk of harm, due to a history of suicidal ideation. In terms of functional status, the records support a score of 3. The documentation noted functional impairment due to significant deficits in the patients ability to fulfill obligations and engage in socially constructive activities.With regard to comorbidity, the records support a score of 3. The patient had comorbidity due to a relapse and significant struggles with alcohol and cannabis use that had a negative impact on mental health. In terms of level of stress of the recovery environment, the records support a score of 3.  The patient had a moderately stressful environment related to a stressful employment situation and the need to return to work. With regard to level of support of the recovery environment, the records support a score of 2, as the patient appeared to have some supportive friendships. In terms of resiliency and treatment history, the records support a score of 3. The patient had moderate or equivocal response to treatment, as her need to return to treatment indicated that past treatment had not enabled her to maintain recovery.With regard to treatment acceptance an engagement, the records support a score of 2. The patient was well engaged in treatment, but had some ambivalence or difficulty connecting to ongoing care. Thus, the patient has a total score of 19. In this case, the recommended level of care is high intensity community-based services. Therefore, IOP level of care that was 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 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 enrollee is requesting authorization and coverage for the medication, Dutasteride 0.5 mg. The enrollee has androgenetic alopecia. His symptoms include hair loss and inflammation with itchiness and pain. He has tried Rogaine, but he reports it made his scalp worse. He has also tried Nizoral, which helped the inflammation, but not the hair loss. He started Dutasteride, 0.5 milligram daily, Finasteride 1 milligram daily, and the topical steroid cream, Fluocinonide, daily. The enrollee was evaluated for a refill of Dutasteride. The enrollee reported he experiences hair loss and a red and painful scalp without the Dutasteride. The provider recommended finasteride, but the enrollees preference was for Dutasteride. Literature shows dutasteride may be superior to finasteride in improving hair growth in young males. However, adverse sexual side effects are more common with dutasteride than with finasteride. Researchers report the therapeutic options with the highest level of evidence remain finasteride and minoxidil for male androgenetic alopecia. This enrollees symptoms include inflammation with itchiness and pain. The use of Dutasteride will decrease dihydrotestosterone levels but it is not an anti-inflammatory; and thus will not treat, nor is it approved for treating, this enrollees inflammation-related symptoms.Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in dermatology 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

The patient is a 36-year-old female with a history of migraines and cluster headaches since 1994, six months after delivery of her second child. The patient has been diagnosed with trigeminal neuralgia. She has been tried on numerous medications, acupressure, acupuncture, massage, and biofeedback, none of which have been effective. The only medication regimen that appears to have been effective is opiates. The patient is currently on Avinza as a baseline medication. She has requested authorization for Actiq for her breakthrough pain, which also causes nausea and vomiting, making oral medication regimens difficult. The Health Plan has determined that Actiq is not medically necessary for treatment of the patients pain.The patient has severe pain, which has failed to respond to conservative treatment. Based upon review of the patients records, her medication regimens are reviewed monthly to ensure appropriateness of her dosages. She also fills out monthly questionnaires indicating the positive benefits of her treatment regimen. As long as the patient continues to be closely followed on her current medication regimen so that abuse of Actiq or other narcotics does not occur, she should be able to continue her current regimen, which has helped her to avoid emergency room visits and allowed her to function at home. Given the severity of the patients intractable pain, continued use of Actiq is medically indicated.Based upon the information set forth above, I have determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a breast ultrasound for evaluation of the enrollees breast cancer screening. Findings:  The physician reviewer found that the request for a breast ultrasound is not medically necessary for evaluation of the patients medical condition. Although screening ultrasonography may mildly increase the number of cancers detected, there are numbers of false positives that include suspicious findings which require further evaluation and possible biopsy that turn out to be benign. In general, the best modality to screen for breast cancer is a routine mammogram. It is optimal to compare like studies, and the patient has a long history of negative mammograms. While some patients experience discomfort with the pressure required with mammography, this is a manageable issue that can be managed by altering the degree of pressure, and by the addition of medications. Considering the lack of any palpable abnormalities and the lack of suspicious findings on the craniocaudal views, the requested breast ultrasound has not been established as medically necessary for evaluation of the patients medical condition. Final Result: The reviewer determined that the requested service is not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in diagnostic radiology 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 Otezla for treatment of his medical condition.  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication.  This patient is currently followed for a diagnosis of inflammatory bowel disease associated arthritis with a possible diagnosis of psoriasis.  The available medical records do not contain adequate documentation that establishes a diagnosis of plaque psoriasis or a diagnosis of psoriatic arthritis.  On the basis of the available medical documentation and per the current recommendations for use of this medication, the requested Otezla  is not medically indicated 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 internal medicine with sub-specialty certification in rheumatology 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 an epidural injection. The Health Plan has denied this request indicating that the requested procedure is not medically necessary for treatment of the enrollees degenerative disc disease. The submitted documentation supports the medical necessity of the requested procedure. Researchers indicated that epidural steroid injection has shown short-term improvement for radicular pain but not for other types of low back pain. A study indicated that there was moderate evidence of short-term benefit of radiculopathy with epidural steroid injection. The medical records provided for review document physical exam findings consistent with radiculopathy; in association with plan for epidural steroid injection; and quantify the duration or degree of relief from previous epidural steroid injection in support of repeat epidural steroid injection. Therefore, the requested epidural steroid injection is medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested procedure 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 with sub-specialty certification in pain management 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 reimbursement for Ultrasound guidance performed during trigger point injections. Within the records available for review, there is documentation that the patient is undergoing treatment for back pain. The provider performed trigger point injections with ultrasound guidance. However, while medical evidence identifies that ultrasound does allow for real-time imaging and can increase the success rate of injection, there is a lack of controlled studies to support this technique of ultrasound guidance as standard therapy. Medical literature noted that, ultrasound allows real-time imaging of the spread of the injectate around the relevant structures and increases the success rate of injection. However, in a more recent study, researchers concluded that, issues with clinical relevance, limited sample sizes, and small point estimates warrant more high-quality research to better characterize the possible value of ultrasound-guided injections. There is a need for additional clinical studies to evaluate the efficacy of using ultrasound guidance compared with the conventional technique of trigger point injection without ultrasound guidance. Given these findings, the ultrasound guidance performed during trigger point injections was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings:  Three of the three physician reviewers found the ultrasound guidance performed during trigger point injections was 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 services at issue were 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 physical medicine and rehabilitation with subspecialty certification in pain medicine and is actively practicing. Physician reviewer 2 is board certified in anesthesiology with subspecialty certification in pain medicine and is actively practicing. Physician reviewer 3 is board certified in anesthesiology with subspecialty certification in pain medicine 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 enrollee has requested a high intensity focused ultrasound (HIFU) procedure for treatment of his prostate cancer. Three physician reviewers found that the services at issue were not likely to be more effective for this patient than other available treatment options. HIFU is a non-surgical, minimally invasive treatment option using ablative technology developed in the 1990s and is now becoming an alternative to radiation therapy. The role of HIFU as primary therapy for patients with prostate cancer is still controversial. In this case, the patient has localized prostate cancer which can be treated with several well-established and proven treatments including surgery, intensity-modulated radiotherapy (IMRT), and brachytherapy. HIFU has been used to treat prostate cancer and there are few published clinical data available. However, these data include small studies published from single institutions. There is a lack of randomized trials or large cohort trials supporting safety and efficacy of HIFU. Based on the records provided and medical literature cited, the HIFU procedure was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.  Final Result:  Three reviewers determined that that the services at issue were 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:   One reviewer is board certified in urology and is actively practicing.  Two reviewers are board certified in radiation oncology and are actively practicing.  All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested Epclusa for 12 weeks for treatment of the enrollees chronic hepatitis C virus genotype 3. Findings: The physician reviewer found that according to 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 life expectancy less than 12 months due to non-liver-related conditions. The recommendations apply regardless of fibrosis stage. Per the guidelines, Epclusa for 12 weeks is recommended as first-line therapy for treatment-naive genotype 3 patients. This is based on the ASTRAL-3 trial for Epclusa, which showed a 98% cure rate (Foster, et al). Delay in treatment may result in decreased survival (Jezequel, et al). For these reasons, Epclusa 400/100 mg 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:   An enrollee has requested digital breast tomosynthesis for evaluation of her medical condition.  Findings:  Two physician reviewers found that breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. There is sufficient support in the peer-reviewed literature for the services at issue in the routine screening population. According to the study by Ciatto and colleagues, the addition of breast tomosynthesis reduces false positives and increases cancer detection when compared to two-dimensional mammography alone. Moreover, Detection rates, including those for invasive and in situ cancers, were 6.1 per 1000 examinations for mammography alone and 8.0 per 1000 examinations for mammography plus tomosynthesis (Skaane, et al). Given the support above, the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.  Final Result: Two reviewers determined that the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications:   All three reviewers are board certified in diagnostic radiology and are actively practicing. All three reviewers are expertst 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: Upheld

A 53-year-old female enrollee has requested for an emergency room for treatment of her severe bloating and diffuse pain. Findings:  The physician reviewer found that a patient must be suffering from symptoms of such severity that a prudent layperson would expect the lack of immediate medical attention to jeopardize her health. This patient admitted that she had suffered similar symptoms in the past related to her gastroesophageal reflux disease. She had stopped taking medication prescribed for her symptoms. Her pain was not severe and had commenced over several hours. Her symptoms do not meet the prudent layperson standard for an emergency.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Vemlidy for one year for treatment of the enrollees hepatitis B. Findings:  The physician reviewer found that the physician reviewer found the current medical evidence supports the requested medication in this clinical setting. Guidelines for the treatment of hepatitis B from the American Association for the Study of Liver Disease (AASLD) recommend entecavir and tenofovir compared with alternatives for the treatment of chronic hepatitis B. In comparison with tenofovir disoproxil fumarate (Viread), the Vemlidy formulation of tenofovir is effective for hepatitis B, but is associated with lower incidence of side effects such as osteopenia and renal disease. Therefore, Vemlidy for one year is medically necessary for the treatment of this patient.  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: Experimental/Investigational
Decision: Upheld

A 49-year-old female enrollee requested authorization and coverage of a gastric bypass surgery with duodenal switch for the treatment of morbid obesity.  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 a gastric bypass surgery with duodenal switch is not likely to be more beneficial for treatment of the enrollees morbid obesity 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.