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

A 33-year-old female enrollee has requested the extraction of deep vein thrombosis for treatment of her chronic left leg deep vein thrombosis.  Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the requested services. Percutaneous management of deep vein thrombosis by interventional radiology is typically utilized for acute deep vein thrombosis in the supra-inguinal or iliac vein region. There is a lack of peer-reviewed literature that supports percutaneous de-clotting for chronic deep vein thrombosis located in the popliteal and femoral regions. The standard treatment for this patients condition is oral anticoagulation. Based upon the documentation submitted for review and the peer-reviewed literature cited above, the medical necessity of the requested extraction of deep vein thrombosis has not been established in this clinical setting.
Appeal type: Medical Necessity
Decision: Overturned

A 68-year-old male enrollee requested authorization and coverage of the medication Zetia. The Health Plan denied the request indicating that the requested medication is not medically necessary for treatment of the enrollees coronary artery disease.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plans denial on the basis that the requested medication is medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a female enrollee requested inpatient psychiatric hospitalization services for treatment of the enrollees major depressive disorder, gender dysphoria, and multiple past suicide attempts. Findings: The physician reviewer found that this patient has several chronic problems that add to her depression and make her prone to sudden thoughts of self-harm or suicide. The treatment team was working with the patients family to help them understand her gender dysphoria and develop a treatment strategy. Without improvement in the family dynamics, the patient was likely to continue to engage self-harm if not in a highly structured environment. The notes indicate that even in such an environment, she continued to have some increase in suicidal thoughts. As soon as she contracted for safety, she was discharged the next day to partial hospitalization program (PHP). Thus, the initial inpatient psychiatric hospitalization services were medically necessary for treatment of the patients medical condition.  Further, it was noted that the patient was readmitted with strong suicidal thoughts and a plan to either overdose or use a tourniquet-like object, which she has at home, to asphyxiate with the intent to end her life. The patient continued to have suicidal ideation and subsequently was finally feeling brighter with better coping strategies. Accordingly, the documentation supports the medical necessity of the initial and subsequent inpatient psychiatric hospitalization services. However, the additional services provided after that period were not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  The parent of an enrollee has requested residential treatment center (RTC) services for treatment of the enrollees medical condition.   Findings:  The physician reviewer found that the records provided for review indicate that this patient no longer met standard criteria for RTC level of care. The notes indicate that she was very compliant with treatment and was developing insight as well as coping skills to deal with her issues. She was not overtly experiencing any hallucinations and was not a risk of harm to herself or others. Her medications were adjusted and stable and she was participating in family therapy. Thus, her treatment could have been continued safely in a less structured setting. For these reasons, the RTC services at issue were not and are not medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the services at issue were not and are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: The reviewer is board certified in psychiatry with sub-specialty 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: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Buprenorphine for treatment of his chronic back pain. Findings:  The physician reviewer found that in this patients case, the requested Buprenorphine is not medically necessary for treatment of his medical condition. Current standard of care for chronic pain is treatment in a multidisciplinary practice to include physical therapy, massage therapy, behavioral therapy, and injections to help reduce pain. Based on a study by Mafi and colleagues, there are Well-established guidelines for routine back pain stress conservative management, including use of nonsteroidal anti-inflammatory drugs (NSAIDs) or acetaminophen and physical therapy, but avoiding early imaging or other aggressive treatments, except in rare cases, such as acute neurologic compromise or other red flags, including a history of malignant neoplasms. Similar findings are reflected in a report by Karppinen and colleagues which states that Conservative decisions in the treatment of degenerative disk disease are based on interventions made for patients with chronic low back pain (LBP). There is convincing evidence that patient education, exercise therapy, and cognitive behavioral therapy are the cornerstones for the treatment of chronic LBP sufferers. Furthermore, these therapies work best in a multidisciplinary rehabilitation context. Pain medication is needed for most patients with degenerative disk disease, and surgery may be needed for a minority only. There are a variety of anticonvulsants and antidepressants considered adjunctive to pain management therapy. High dose opioids are associated with a high risk of dependence and tolerance; therefore, they are not recommended for treatment of chronic pain. Medical studies show that short-acting opiates are more likely to cause adverse outcomes. Therefore, based on the available medical literature and in consideration of the presented clinical records, Buprenorphine is not medically necessary for treatment of this 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 28-year-old male enrollee has requested an Otto Bock C-leg microprocessor controlled knee for treatment of his above-knee amputation.  Findings:  Two physician reviewers found that this patient is a highly functional ambulator with a prosthesis that is no longer safe for both skin and mobility reasons. The patients mobility needs require varied cadence and stability with stance phase. The proposed microprocessor controlled knee prosthesis is a medically reasonable functional choice for this patient and will best allow him to meet his mobility needs.
Appeal type: Urgent Care
Decision: Upheld

A 60-year-old male enrollee has requested for emergency services for treatment of his dental pain. Findings:  The physician reviewer found that the patients pain had been present for five days and was rated as 6/10. He denied fever, chills, facial swelling or any other associated symptoms. On exam, the patient had poor dentition, caries on the right lower and upper incisors with mild soft tissue swelling at the gingival/buccal mucosa margin and tenderness to light palpation. He was diagnosed with dental caries with gingivitis and possible early dental abscess and prescribed an oral antibiotic.A prudent layperson with an average knowledge of medicine and 6/10 dental pain without other associated symptoms would not expect the absence of immediate emergency care to jeopardize his health. This patient could have been safely evaluated on a non-emergent basis.
Appeal type: Experimental/Investigational
Decision: Upheld

Findings:  The physician reviewer found that An enrollee has requested reimbursement for three-dimensional (3D) fetal ultrasound. The provider noted that this patient has a history of incompetent cervix and delivery by Cesarean section x 2. The provider noted that the patient underwent evaluation with an abdominal and transvaginal obstetrical ultrasound for evaluation of cervical length. The ultrasound also revealed 3D imaging of the fetal face. As noted by the American Institute of Ultrasound in Medicine (AIUM), limited fetal ultrasound in the second trimester does not require assessment of the fetal face in 3D. This patient underwent ultrasound with 3D imaging of the facial features of the fetus. Although the ultrasound was appropriate to evaluate the patients cervical length, the 3D rendering of the facial features of the fetus is not supported by the guidelines or medical literature. Accordingly, the 3D fetal ultrasound was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Findings: Two of the three physician reviewers found the services at issue were 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 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.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:   An enrollee has requested Olysio and Sovaldi for treatment of his hepatitis C.  Two physician reviewers found that the current medical evidence supports the requested medications in this clinical setting.  Per the American Association for the Study of Liver Diseases and Infectious Diseases Society of America guidelines, all patients with chronic active hepatitis C should be treated regardless of fibrosis score.  The medical evidence supports treatment in all patients with hepatitis C, except those with limited life expectancy less than 12 months due to non-liver-related comorbid conditions.  The goal of treatment is to reduce all-cause mortality and liver-related health adverse consequences, including end-stage liver disease and hepatocellular carcinoma.  All told, the requested Olysio and Sovaldi are medically indicated for the treatment of this patient.  Final Result: Two reviewers determined that the requested medications are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: All 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollees parent has requested authorization and coverage for tolerance induction program. As noted in recent review articles, oral immunotherapy treatment is in the early stages of development and further studies are necessary to optimize the protocols and improve safety. The potential therapeutic benefits of oral immunotherapy need to be considered in terms of significant oropharyngeal, respiratory, and gastrointestinal symptoms that have led to cessation of therapy in an estimated 10-15% of treated patients. Oral immunotherapy has not been recommended for the treatment of patients with food allergies by the AAAAI due to uncertainty whether therapeutic benefit outweighs risk of treatment. According to the AAAAI, the interventions and endpoints used in clinical trials vary widely. As a result, neither safety nor efficacy have been established a tolerance induction program as superior to allergen avoidance. This patient has a history of allergies to foods including peanuts, which supports treatment with food avoidance and use of an epinephrine autoinjector as needed. Given these findings, the requested tolerance induction program is 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 requested tolerance induction program 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 services are 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 allergy and  immunology with subspecialty certification in pediatrics and is actively practicing. Physician reviewer 2 is board certified in allergy and  immunology and is actively practicing. Physician reviewer 3 is board certified in internal medicine with subspecialty certification in allergy and immunology 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: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested intensive outpatient program (IOP)services for treatment of the enrollees autism and anxiety disorder. Findings: The physician reviewer found that in this clinical setting, continuation of IOP interventional therapy is not medically necessary. The patients history indicates that the patient was initially referred to the IOP program when he was receiving ABA treatment only 3 days each week. The documentation stated that his behaviors were severe but he improved with the IOP treatment.  Most likely, this is because the treatment time was increased as per Academy of Child and Adolescent Psychiatry (AACAP) guidelines. Per AACAP practice parameters, the guidelines for treatment of ASD state that treatment for young children should be intensive and highly individualized, with up to 40 hours per week of one-to-one direct teaching, initially using discrete trials to teach simple skills and progressing to more complex skills such as initiating verbal behavior. In sum, the standard of care in this setting is intensive ABA services (up to 40 hours per week). This patients records do not indicate that he needs higher level of care through IOP services; rather, the patient is an appropriate candidate for intensive ABA therapy in order to control his symptoms and to prevent further regression. For these reasons, the requested IOP services are not medically necessary for treatment of this patients autism spectrum disorder (ASD) and anxiety.  Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients behavioral condition. Therefore, the Health Plans denial should be upheld. Qualifications/Credentials: The reviewer is board certified in psychiatry with sub-specialty 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

The patient has requested authorization and coverage for magnetic resonance imaging (MRI) of the cervical spine and MRI of the right shoulder. The American College of Radiology (ACR) guideline indicates that MRI of the cervical spine may be appropriate for patients with prior cervical spine surgery with new or increasing non-traumatic cervical or neck pain or radiculopathy. This patient presents with a history of chronic neck pain with left upper extremity radicular symptoms. Prior cervical spine imaging demonstrated multilevel and multifactorial stenosis with cord flattening and indentation. The patients current symptoms include a wobbly gait, which represents a possible neurologic progression. There is evidence of failure of physical therapy and home exercise. The provider referred the patient to a neurosurgeon, who has requested an updated MRI prior to evaluation. Current evidence based medical literature support an updated cervical spine MRI for progressive neurologic symptoms, failure of conservative treatment, and for treatment planning purposes. Therefore, the requested MRI of the cervical spine is medically necessary for this patient. There is no lack of documentation of referral to a pain management physician or evidence that additional diagnostic studies are required to determine a treatment plan. Accordingly, the requested MRI of the right shoulder is not medically necessary for evaluation of this patient.Final Result: The reviewer determined that a portion of the requested services is medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be partially 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the iStent trabecular micro-bypass procedure for treatment of the enrollees primary open angle glaucoma. Findings:  The physician reviewers found that The iStent is a minimally invasive device that has been approved by the U.S. Food and Drug Administration (FDA) for the treatment of glaucoma in patients who are undergoing cataract surgery. The iStent device has been found to be effective in patients with mild-to-moderate glaucoma who are undergoing cataract surgery at the same time. The overall effect of the iStent on the intraocular pressure is modest and its use is not appropriate for patients who have advanced glaucoma and an intraocular pressure that is uncontrolled with medication. Since the patient meets these criteria, the use of iStent trabecular micro-bypass procedure was likely to be more beneficial than standard therapy. Final Result: All three reviewers determined that the service at issue was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewer number one, two, and three are board certified in ophthalmology 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for DecisionDx-Melanoma gene test for evaluation of the enrollees cutaneous melanoma. Findings:  Three physician reviewers found that the standard protocol based on National Comprehensive Cancer Network (NCCN) guidelines for an intermediate thickness tumor, like this patients, does not include a workup with molecular genetic testing. Currently, although the testing has shown some impressive results in predicting risk of metastasis, there is no set change in treatment protocol based on the findings. Currently, the protocol would be a wide local excision and a sentinel node biopsy and the decision to pursue medical treatment would be based on the results of these tests. There is a lack of clinical studies at this time to show that the results of the molecular testing will make a difference in the treatment or morbidity of the patient. Final Result: The 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: Reviewers 1, 2 and 3 are board certified in dermatology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 34-year-old female enrollee has requested for awake brain tumor resection with brain mapping for treatment of her brain tumor.  Findings:  The physician reviewer found that the patients tumor was in a high-risk area and standard non-awake craniotomy would have been a dangerous procedure with little likelihood of a positive outcome in terms of functional and cognitive preservation. Appropriate surgical intervention required state-of-the-art technology and an experienced surgeon. Awake craniotomy was the right procedure and was performed without apparent harm to patient.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Humira 40 mg every five days. The American Gastroenterological Association (AGA) guidelines for therapeutic drug monitoring recommend a Humira level of 7.5 ug/mL or higher (Feuerstein, et al.). This patients therapeutic drug monitoring revealed a Humira level of 7.7 mcg/mL. The Humira level in this case is adequate. The AGA guidelines recommend that in patients with a normal Humira level, low level of anti-Humira antibodies, and lack of objective inflammation, continue drug at current dose and look for other causes for symptoms. This patient has objective evidence of controlled Crohns disease on the current dose, with normal colonoscopy, and normal fecal calprotectin. Anti-tumor necrosis factor medications such as Humira can be associated with significant risks at standard dosing, and these risks may be elevated at doses higher than the U.S. Food and Drug Administration (FDA) approved dose. For these reasons, the requested Humira 40 mg every five days is not medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested medication dosage 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 subspecialty 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.