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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for intensive outpatient program (IOP) services. The 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. Applying LOCUS guidelines, the patient met the criteria for IOP services. The patient was at moderate risk of harm (score 3) due to recent suicidal ideation and impulsive behaviors. The records document that the patient expressed suicidal ideation due to conflicts with his family. The patient demonstrated moderate functional impairment (score 3), given his problems in interpersonal interaction and difficulty attending treatment. The patient had no major comorbidities (score 2) as he was overall medically stable without evidence of substance use. He continued to have symptoms of mental illness including depression and anxiety. The patients recovery environment was mildly stressful (score 2) due to a stable living environment but strained relationship with his family. The patient had limited support in his recovery environment (score 3) due to few supportive resources. The patient demonstrated moderate response to treatment (score 3) considering his recent treatment response in the IOP, but the presence of persistent symptoms. The patient was obstructive in treatment (score 3) due to fair cooperation in treatment but limited ability to accept responsibility for his recovery. The progress notes during the disputed period indicate that the patient was minimally cooperative in treatment. The patient showed some minimal commitment to therapy but also exhibited counterproductive behaviors. The patient demonstrated limited insight into his need for treatment, was late to treatment, and missed sessions. This gives the patient a composite score of 19, which correlates with high intensity community based services, such as IOP. All told, the documentation supports that the IOP 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 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: The patient has requested authorization and coverage for budesonide extended release, 3 mg. The American Association for the Study of Liver Diseases (AASLD) support treatment with budesonide as a first-line corticosteroid therapy for patients with autoimmune hepatitis. The AASLD guidelines cite a lower risk of systemic side effects such as myalgias with budesonide than prednisone. This patient has a contraindication to prednisone as the risk of tuberculosis reactivation dramatically increases with systemic corticosteroid use. Moreover, she is not an ideal candidate for treatment with prednisone due to side effects including myalgias. Current data have shown that budesonide is effective with or without azathioprine for the treatment of autoimmune hepatitis, and the AASLD guidelines support corticosteroid monotherapy when azathioprine is contraindicated. The patients provider has recommended that she avoid azathioprine due to the presence of latent tuberculosis. For these reasons, the requested budesonide extended release, 3 mg is medically necessary for 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 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.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for minimally invasive surgery to treat L4-S1 spondylosis and stenosis and L4-L5 spondylolisthesis. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  A study concluded that the current evidence does not support the routine use of minimally invasive surgery for cervical or lumbar discectomy. Well-designed trials are needed given the lack of high-quality evidence.  This patient presents with worsening low back pain radiating into the lower extremities with symptoms of neurogenic claudication.  He has been diagnosed with L4-S1 spondylosis and L4-L5 spondylolisthesis. He has failed to improve despite reasonable conservative treatment. The in-Plan providers have recommended L4-S1 laminectomy, posterior instrumented fusion, and L4-L5 transforaminal lumbar interbody fusion.  The patient has requested minimally invasive surgery, but a specific procedure has not been proposed.  There is limited evidence-based guideline and peer-reviewed literature evidence to support minimally invasive lumbar surgery over standard lumbar spine surgery for this patients medical condition. Therefore, the requested minimally invasive surgery to treat L4-S1 spondylosis and stenosis and L4-L5 spondylolisthesis is not medically indicated 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 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 mother of a seven-year-old male enrollee has requested myofunctional therapy for treatment of the enrollees oral condition. Findings:  The physician reviewer found that there is no documentation of oral, facial, or tongue dysfunction in this patient, other than reports by the orofacial myologist.  The specialty of orofacial myology has some recognition among speech pathologists and dentists, but it is not a recognized medical specialty.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for (1) Gammagard intravenous infusions (two grams/kg monthly) and (2) administration of Gammagard in a hospital-based infusion center.  Findings:  The physician reviewer found that Neuromyotonia is characterized by muscle cramps and stiffness, often along with concurrent neuropathy, as in this case. Fleisher and colleagues report that treatment with phenytoin, carbamazepine, or gabapentin has provided symptomatic relief in some patients. The authors further note that for patients who do not respond to this type of treatment, immunotherapy with plasmapheresis, intravenous immune globulin (IVIG), or steroids may be beneficial. However, the authors conclusions were regarding a single case. Given that the evidence in current medical literature supporting the use of IVIG for management of neuromyotonia is limited and anecdotal, the requested service is not medically indicated. Therefore, (1) Gammagard intravenous infusions (two grams/kg monthly) and (2) administration of Gammagard in a hospital-based infusion center are not 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 neurology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 61-year-old female enrollee has requested authorization and coverage for pulse electrical stimulation for treatment of the enrollees end-stage osteoarthritis.  Findings:  The physician reviewer found that the efficacy of pulsed electrical stimulation, the basis of the BioniCare system, for treatment of osteoarthritis of the knee, has not been demonstrated (McCarthy, et al). Evidence of efficacy is insufficient and there remains a need for appropriately designed trials (Rufus, et al). The effectiveness of pulsed electrical stimulation in the management of osteoarthritis of the knee remains unclear (Varken, et al). Until this evidence is available, this therapy remains unproven and therefore is not medically necessary for treatment of this patients knee osteoarthritis.
Appeal type: Experimental/Investigational
Decision: Upheld

A 45-year-old male enrollee requested radiofrequency neurolysis for medical treatment of his back and neck pain.  Findings:  Three physician reviewers found that radiofrequency neurolysis is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. In this case, the patient has undergone facet joint injections in multiple regions with steroid and normal saline. Radiofrequency neurolysis is clinically indicated for patients with an established diagnosis with controlled diagnostic blocks based on symptomatology. However, the patient has not undergone any type of diagnostic interventions to delineate the presence of facet joint pain in a complex patient. All told, the requested treatment is not appropriate for this patient. Therefore, based on the reasons provided above, the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:   An enrollee has requested podiatry services for treatment of her toe pain.  The physician reviewer found that the submitted documentation establishes the medical necessity of the requested services. In this case, the request for a podiatry referral for this patients right foot pain is medically reasonable and necessary. The progress note from the primary care physician documents a hallux valgus and hammertoe deformity of the right foot along with pain to the area. X-rays revealed a hallux valgus deformity with osteoarthritic changes to the first MPJ. The physical findings of pain to the right foot first MPJ area coupled with the x-ray findings of hallux valgus and osteoarthritis changes of the first MPJ together establish the medical necessity for a podiatry referral for treatment. For these reasons, podiatry services are medically necessary for 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 podiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 57-year-old female enrollee has requested acute inpatient detoxification for the treatment of the enrollees chemical dependency. Findings:  The physician reviewer found that the submitted clinical evidence demonstrates that upon admission the patient was detoxing from opiates with no life-threatening withdrawal signs or symptoms. There is no evidence that the patient was experiencing benzodiazepine withdrawal during the period at issue. Thus, per American Psychiatric Association and American Society of Addiction Medicine (ASAM) criteria, the patient could have been safely detoxed in an outpatient setting and did not require a 24-hour detoxification program for her withdrawal.
Appeal type: Experimental/Investigational
Decision: Upheld

A 60-year-old male enrollee has requested transcranial magnetic stimulation (TMS) therapy for treatment of his behavioral health condition.  Findings:  Two physician reviewers found that the patients most recent diagnosis is bipolar disorder, and this procedure has been poorly studied for this condition. Studies by Nahas and colleagues and Kaptsan and colleagues found no benefit from TMS therapy for this diagnosis. Additional complicating factors include the presence of Axis II comorbid conditions. There is a lack of evidence indicating that TMS therapy is effective in patients with major depression and comorbid conditions. A recent study by Eranti and colleagues comparing the two modalities shows that ECT is more effective. Furthermore, the limited clinical information supplied does not establish that the patient has tried and failed antidepressant medication trials, as it is not established that he has had an adequate trial in terms of dose and duration. All told, TMS therapy is not likely to be more efficacious than other treatment alternatives in this patients case.
Appeal type: Medical Necessity
Decision: Upheld

A female enrollee requested hip surgery for medical treatment of the her left hip pain. Findings:  The physician reviewer found that this patients clinical documentation provides evidence of complete obliteration of superior articular cartilage in the hip joint, with subchondral cyst formation and diffuse sclerosis. However, the clinical documentation does not document that the patient has been diagnosed with osteoarthritis of the hip. Further, there is a lack of evidence that the patient has participated in and failed conservative medical therapy including physical therapy. For these reasons, the requested hip surgery is not supported as medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

This patient is a 40-year-old female who is 59 weighing 205 pounds. The patient has a hanging pannus, which is stated to have developed post gastric bypass though one physicians notes indicate a gastric stapling procedure was performed. There is evidence she has been seen and evaluated by an orthopedic surgeon for probable obesity related knee problems. The patient wishes to undergo an abdominoplasty. The Health Plan has denied the request on the basis that the requested procedure is not medically necessary.There is no evidence the patient has undergone an appropriate evaluation by a plastic surgeon or other surgeon experienced in post massive weight loss excess tissue removal procedures. While there may be valid reasons to consider removal of the pannus, they are not documented in the records presented. As such, there is insufficient documentation the proposed procedure is medically indicated. Therefore, I have determined that the requested procedure is not medically necessary for treatment of the patients medical condition. The Health Plan s denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Overturned

A female enrollee requested breast reconstruction using autologous fat grafting and adipose-derived stem cells for medical treatment of the enrollee, who is status post bilateral breast reconstruction revision.  Findings:  Two physician reviewers found that the requested services are supported by the current medical evidence and are specifically used for contour defects, including ones associated with breast reconstruction.  Additionally, fat grafting is considered standard treatment in this clinical setting.  All told, the requested autologous fat grafting and adipose-derived stem cells are likely to be superior over other available treatment options.
Appeal type: Medical Necessity
Decision: Upheld

The patient has requested authorization and coverage for cognitive behavioral therapy (CBT) services for 45 minutes once weekly. Based on the available documentation, CBT therapy is appropriate to treat this patients presenting concerns. However, the provision of these services with an independent provider are at the patients convenience, which does not meet medical necessity criteria. Current evidence-based criteria and meta-analyses of CBT support services with a provider within the Health Plans network. The provider has not offered any information that highlights how the independent providers services are different from other providers trained in CBT. Researchers noted that CBT is a broad service delivery modality that is widely used to treat many disorders. Researchers also reported that CBT is one of the most effective treatments identified for the treatment of anxiety, depression, schizophrenia, and bipolar disorder. Given this information, the patient should receive CBT therapy with a provider within the Health Plans network. Therefore, the requested CBT services for 45 minutes once weekly are not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is a licensed B.C.B.A, board certified in psychology, and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 53-year-old female has requested coverage for an abdominal panniculectomy for treatment of her abdominal pannus.  Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the requested procedure.  An abdominal panniculectomy may be medically necessary for patients with a documented history of recurrent infections.   However, in this patients case, there is no documentation of office visits for treatment of a skin condition related to the pannus.  Additionally, the submitted documentation does not demonstrate that the pannus interferes with function, such as ambulation. The presence of a pannus and/or its psychological or physical burden on the patient does not automatically make its removal medically necessary.  In this patients case, the condition does not constitute an abnormal structure of the body.  The standard medically indicated procedures for this patient are hernia repair and bariatric gastrointestinal weight loss surgery.  All told, the requested abdominal panniculectomy is not reconstructive in nature and is not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

A 43-year-old female enrollee requested authorization and coverage of gastric bypass surgery with duodenal switch. The Health Plan denied the request indicating that the requested procedure is not medically necessary for treatment of the enrollees morbid obesity.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested procedure is not medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for a coronary computed tomography angiography (CCTA). Findings: Two physician reviewers found that some preoperative assessment of coronary anatomy is reasonable and appropriate, since concomitant coronary artery bypass would be strongly considered if significant stenosis were identified.  Both CCTA and conventional coronary angiography assess coronary anatomy but conventional coronary angiography is preferred, given its improved accuracy relative to CCTA. In this patients case, conventional preoperative coronary angiography is appropriate and considered standard accepted practice in the medical community. Final Result: The reviewers determined that the procedure at issue was 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 internal medicine with sub-specialty certification in cardiovascular disease 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: An enrollee has requested Harvoni for treatment of her hepatitis C virus genotype 1a.  Findings:  The physician reviewer found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. The guidelines recommend that all patients should be treated, regardless of fibrosis stage. The guidelines recommend that treatment-naive genotype 1a patients should be treated with Harvoni for 12 weeks. These guideline recommendations are based on multiple randomized clinical trials, and the medication is U.S. Food and Drug Administration (FDA)-approved for all patients with chronic hepatitis C genotype 1 regardless of fibrosis stage (Kowdley, et al; Afdhal, et al). The patient is ineligible for the alternative, Viekira Pak with ribavirin, due to pre-existing medical conditions, which can be induced or exacerbated by ribavirin as shown in a placebo-controlled trial of ribavirin monotherapy (Dusheiko, et al). AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment (Jezequel, et al). For these reasons, the requested treatment with Harvoni 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.