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

The parent of an 11-year-old female enrollee has requested  for Genotropin growth hormone therapy for treatment of the enrollees idiopathic short stature.  Findings:  The physician reviewer found that applying the guidelines discussed by Cohen and colleagues, a trial of GH therapy should be approved for young patients with otherwise unexplained short stature who pass GH stimulation tests but who meet most of the following criteria: (1) height more than 2.25 SDs below the mean for age, or more than 2 SDs below the mid-parental height percentile; (2) growth velocity less than 25th percentile for bone age; (3) bone age more than 2 SDs below the mean for age; (4) low serum IGF-1 and/or IGFBP-3; and/or (5) other clinical features suggestive of GH deficiency. Based on the information provided, this patient meets most of these criteria. She has idiopathic short stature, with a current height prediction that is approximately 3 SDs below normal for age and gender. This calculation is also below her estimated final height based on her genetic potential.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Adderall sustained release 5 mg daily and increase to 10 mg after one week. Findings:  The physician reviewer found that adults with attention deficit hyperactivity disorder (ADHD) are more frequently presenting for diagnosis and treatment, and that medication is considered as an appropriate treatment. The authors further note that aggregate literature shows that stimulants have a clinically significant beneficial effect in treating ADHD in adults. Santosh and colleagues note that there is some evidence that stimulant medication can improve driving performance in adults with ADHD. The U.S. Food and Drug Administration (FDA) approves the use of Adderall for the treatment of ADHD. Given that current medical literature supports the safety and efficacy of Adderall in the treatment of ADHD, the requested medication regimen is medically indicated. Therefore, Adderall sustained release 5 mg daily and increase to 10 mg after one week is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested medication regimen 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 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 a 12-week course of Sovaldi for treatment of his hepatitis C.   Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested medication.  Per 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 requested treatment regimen is standard of care for the treatment of patients with hepatitis C, genotype 2 infection.  All told, the requested 12-week course of Sovaldi is medically indicated 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: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for thyroid radiofrequency ablation (CPT 60699). Findings:  The physician reviewer found that records provided for review document that this patient has a history of an enlarging thyroid nodule. The nodule has grown compared to previous ultrasound. One of the patients providers has recommended treatment with radiofrequency ablation. Per Chung and colleagues, radiofrequency ablation is a safe treatment of benign thyroid nodules and recurrent thyroid cancers. Feroci and colleagues reported that radiofrequency ablation of thyroid nodules has been found to be safe and effective in reducing the size of a thyroid nodule without the need for open surgery in a majority of patients with low complication rates. Given this support, the requested thyroid radiofrequency ablation (CPT 60699) is medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in otolaryngology 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 patient requested a referral for magnetic resonance neurography (MRN). Findings:  The physician reviewer found that in this case, the patient has a history of lower extremity pain of uncertain etiology. EMG/NCS, MRI of the lumbar spine, and MRI of the lumbar plexus were normal or non-diagnostic. The patients neurological examination was also normal. In this setting, it would not be expected that performance of a repeat imaging study of the same anatomic region with MRN would lead to any new findings. Published medical literature does not support the clinical utility of MRN in this clinical setting. Specifically, it is unclear how MRN imaging would lead to improvements in the management of the patients care. Overall, the medical evidence does not suggest that the requested service will yield data beyond that obtained with imaging already performed. Therefore, the requested MRN is not medically necessary for the evaluation of this patient.Final Result: The reviewer determined that the requested service 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 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: Experimental/Investigational
Decision: Overturned

A 61-year-old female enrollee has requested Botox injections for the treatment of her muscle spasms. Findings:  Two physician reviewers found that this patient has severe idiopathic torsion dystonia and has required multiple drug therapies and hospitalization. This patients symptoms are currently not well-controlled despite standard first-line care and multiple medication use. There is an abundant amount of literature citing the benefit of Botox for dystonic conditions. This patient will likely benefit from a trial of Botox. Botox therapy is considered a second-line therapy and is the standard in refractory cases such as the one presented here.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Genetic testing (Oncology (prostate) gene expression profile by real-time polymerase chain reaction (RT-PCR) of three genes (ERG, PCA3, and SPDEF), urine, algorithm reported as risk score). This patient presents with elevated prostate specific antigen (PSA) and benign prostatic hyperplasia (BPH). The patient underwent ExoDx testing, which revealed a 91% chance of no high grade prostate cancer. As noted in the peer-reviewed medical literature, the use of ExoDx testing to forego biopsy in patients with increasing PSA and negative magnetic resonance imaging (MRI) has not been demonstrated to improve clinical patient health outcomes. Additionally, the use of ExoDx to forego biopsy and treat patients with benign prostatic hyperplasia (BPH) without biopsy in rising PSA, has not been shown to provide improved predictive value over MRI alone. For these reasons, the genetic testing (Oncology (prostate) gene expression profile by real-time polymerase chain reaction (RT-PCR) of three genes (ERG, PCA3, and SPDEF), urine, algorithm reported as risk score) was 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 genetic testing (Oncology (prostate) gene expression profile by real-time polymerase chain reaction (RT-PCR) of three genes (ERG, PCA3, and SPDEF), urine, algorithm reported as risk score) was 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. Credentials/Qualifications: Physician reviewer 1 is board certified in urology and is actively practicing. Physician reviewer 2 is board certified in urology and is actively practicing. Physician reviewer 3 is board certified in urology 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

The patient is a 10-month-old male with documented deformational plagiocephaly and mild torticollis. He was evaluated by neurosurgery and treatment with cranial orthotic therapy was recommended. The patients parents have requested authorization for the cranial remolding orthosis. The Health Plan denied their request based upon a determination that the device is not medically necessary.Since it is now recommended that infants sleep exclusively on their backs, plagiocephaly is becoming more common. Although conservative positional treatment is effective in many cases, the use of a cranial remodeling orthosis is required with more severe problems. This patient has been properly evaluated by neurosurgery and given this his significant deformational plagiocephaly and torticollis, cranial remodeling therapy is medically reasonable and appropriate. Therefore, I have determined the device at issue is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for all or any of the residential treatment center (RTC) level of care provided. 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. 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 had a history of suicidal ideation and past attempts with Advil, however the records did not indicate current suicidal ideation or intent. In terms of functional status, the records support a score of 3. The documentation noted ongoing difficulties in interpersonal relationships and ability to function in employment. With regard to comorbidity, the records support a score of 3. The patient reported past issues with substance use but reported being sober at the time of admission. In terms of level of stress of the recovery environment, the records support a score of 3. The patient reported an aversion to returning home due past trauma. However, the records did not identify significant stressors or stress factors to be addressed in the treatment plan.With regard to level of support of the recovery environment, the records support a score of 2 as the patient had a supportive family.In terms of resiliency and treatment history, the records support a score of 4. The patient had equivocal response to past treatment, due to extended abstinence from substance use, but persistent mood and anxiety symptoms. With regard to treatment acceptance an engagement, the records support a score of 2. The patient was well engaged in present treatment, recognized and understood her illness, and demonstrated a desire for recovery. Thus the patient has a total score of 20. In this case, the recommended level of care was medically monitored non-residential services. Therefore, all of the RTC level of care provided was not medically necessary for treatment of this patient.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 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 parent of a 16-year-old female enrollee has requested for residential treatment center services for treatment of the enrollees anorexia nervosa, depression, and anxiety. Findings:  The physician reviewer found that from a developmental perspective, this patient is struggling in her negotiation of identity formation which places her at risk of a healthy and successful second individuation.  Modern psychiatric practice aims to place patients in the least restrictive treatment setting.  In general, community intervention settings are thought to offer optimization of treatment gains.  Per the American Psychiatric Association, when determining the appropriate level of care, it is important to consider the patient's overall physical condition, psychology, behaviors, and social circumstances.  The American Academy of Child and Adolescent Psychiatry Practice Parameter noted that the appropriate level of care depends primarily on the level of function and safety to self and others.  Specifically, severity of depression, presence of suicidal and/or homicidal symptoms, psychosis, substance dependence, agitation, adherence to treatment, and family environment must be considered when determining the appropriate level of care. All told, residential treatment center services were and are medically necessary for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for VenaSeal procedure. Findings:  The physician reviewer found that recent studies have introduced data suggesting that VenaSeal is a promising therapeutic option for patients with chronic venous insufficiency (Kolluri, et al.). However, there is a lack of prospective randomized controlled clinical trials demonstrating that VenaSeal is superior to standard available treatment modalities for use in this patient population. Gibson and colleagues found that VenaSeal is as safe as thermal ablation and effective in achieving closure of the incompetent veins. Overall, there remains a lack of reports describing the long-term effects of VenaSeal since this procedure to support its routine use in the management of this patients recannulated left greater saphenous vein (GSV) in the left leg. Current literature recommends re-treatment with ablation therapy for GSV recanalization (Morrison, et al.). For this patient., re-treatment with ablation is likely to be the most efficacious approach to treating recurrent venous insufficiency. All told, the requested VenaSeal procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.  Findings: Two of the three physician reviewers found the requested VenaSeal procedure 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 radiology with subspecialty certifications in diagnostic radiology, vascular, and interventional radiology and is actively practicing. Physician reviewer 2 is board certified in general surgery with subspecialty certification in vascular surgery and is actively practicing. Physician reviewer 3 is board certified in general surgery with subspecialty certification in vascular surgery 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

Findings:  The physician reviewer found that The patient has requested reimbursement and prospective authorization and coverage for (1) Monovisc injection to the right knee and (2) Euflexxa injections administered as one injection to the right knee and one injection to 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 from organizations such as the American Academy of Orthopedic Surgeons 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 relief from prior viscosupplementation of the right knee. Given the patients limited options and based on the current medical literature, the services at issue were and are medically indicated. Therefore, (1) Monovisc injection to the right knee and (2) Euflexxa injections administered as one injection to the right knee and one injection to the right knee were and are medically necessary for the treatment of this patient.Final Result: The reviewer determined that the services at issue were and are 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 two 40mg OxyContin ER (extended release) per day and four 30mg oxycodone IR (immediate release) per day. Findings:  The physician reviewer found that there is a lack of support for the medical necessity of the requested medications in this clinical setting. Chronic pain that has no hope for a cure can be considered palliative in nature and treatment. The stepwise World Health Organization (WHO) ladder for pain relief is considered the reasonable approach to pain control in the palliative setting. However, in this patients case it is not entirely clear if the work up for the back pain has been finalized. In the documentation available for review, the magnetic resonance imaging has not been performed. Also, drug testing has not been performed under the direct guidance of a medical health professional. The records do not show that all non-opioid medication classes have been optimized or tried. In addition, not all non-opioid treatment options have been utilized. There is no mention of behavior therapy despite much research to support its use. In this patients case, the medications being requested are quite large doses of opioids. The medical evidence shows that continuation of opioid prescribing at higher doses without proper treatment for the substance use disorder sets the patient up for higher morbidity and mortality. In this clinical setting, it is reasonable to consider alternatives to opioids and to have the patient tapered off opioids. Finally, multiple minimal requirements for opioid prescribing have not been performed. The need to use the requested medications as the primary medication treatment strategy for pain has not been established. For all these reasons, two 40 mg OxyContin ER per day and four 30 mg oxycodone IR per day are not medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the requested medications 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 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

A 40-year-old female enrollee requested authorization and coverage of gastric bypass surgery for the treatment of Obesity.  The Health Plan denied the enrollees request indicating that the requested treatment is not medically necessary.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 for treatment of the patients medical condition.