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

Nature of Statutory Criteria/Case Summary:   An enrollee has requested Sovaldi and ribavirin for treatment of her hepatitis C virus genotype 2b. 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. This applies regardless of fibrosis stage or viral load. Per guidelines, treatment-naive genotype 2 patients should be treated with Sovaldi and ribavirin 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 2 regardless of fibrosis stage (Zeuzem, et al; Lawitz, et al; Jacobson, et al). The AASLD and IDSA guidelines do not recommend any other regimens for ribavirin-eligible genotype 2 patients. The guidelines also cite data showing increased survival with earlier treatment (Jezequel, et al). For these reasons, the requested Sovaldi and ribavirin is supported as medically necessary for the treatment of this patients hepatitis C infection. Final Result: The reviewer 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: 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: Upheld

The patient is a 58-year-old female requesting reimbursement of physical therapy services rendered from November 2004 to March 2005. The therapy at issue was provided for treatment of bilateral sacroiliac joint inflammation. The Health Plan has denied reimbursement for the therapy at issue on the basis it was not medically necessary for treatment of the patients condition. The Health Plans denial should be upheld. The physical therapy services the patient received from November 2004 to March 2005 were primarily in the form of passive modalities for passive pain control. There is no evidence the therapy at issue was likely to result in improvement in the patients condition and ability to function in a reasonable and predictable time period. As such, it has not been established the therapy at issue was medically warranted. Accordingly, I have determined the therapy at issue was not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

A female enrollee requested a 3D mammogram (breast tomosynthesis) for medical evaluation of her medical condition.  Findings:  Two physician reviewers found there is a lack of peer-reviewed literature that supports the use of 3D breast tomosynthesis compared to currently available techniques. Although breast tomosynthesis is a promising tool in breast imaging, further evidence is needed to establish its place in breast cancer diagnosis and screening. As such, the 3D mammogram (breast tomosynthesis) was not likely to be more beneficial for evaluation of this patient than standard modalities.
Appeal type: Experimental/Investigational
Decision: Upheld

A 66-year-old female enrollee has requested for laboratory testing (code 82172 apolipoprotein, code 83090 homocysteine, code 83695 lipoprotein(a), code 83698 lipoprotein-associated phospholipase A2, code 83701 lipoprotein, blood, high resolution fractionation and quantitation of lipoproteins including lipoprotein subclasses when performed, code 86141 C-reactive protein, high sensitivity hsCRP and code 82664 electrophoretic testing) for evaluation of the enrollees cardiovascular risk. Findings:  Two physician reviewers found that there is evidence in the medical literature indicating that there is statistical association between levels of the various requested blood measurements and coronary disease.  However, the bulk of evidence indicates that the availability of such detailed measurements does not lead to more effective therapy for hyperlipidemia-associated risks or improve clinical outcomes. Screening for levels of these entities is not beneficial unless the patient has failed to respond to standard therapy, or because of family history or other risk factors, is regarded as being at unusually high risk of developing coronary artery disease.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: A 26-year-old male enrollee has requested reimbursement for the residential treatment center  services. The patient did not report post-acute withdrawal symptoms. He was not a danger to himself or others, nor was he aggressive or violent. He was cognitively intact and he was not gravely disabled. There were no emotional, behavioral, cognitive, or impulsive symptoms that would warrant this level of care. He was medically and psychiatrically stable. There was no evidence of a high degree of impulsivity, agitation, depression, mania, hallucinations, or any other significant symptom that would interfere with his care. He was motivated and appeared to be working the program. He was cooperative and participating in his treatment plan. Although he continued to struggle with his emotions and required further treatment to help develop coping skills, this did not require the structured residential setting with 24-hour nursing and medical monitoring. Based on the available documentation, the patient could have been safely and adequately treated at a less restrictive level of care. All told, the RTC services provided  were not medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the services at issuer 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 with sub-specialty certification in addiction 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. Findings:  The physician reviewer found that
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for residential treatment center (RTC) services. The Child and Adolescent Level of Care Utilization System (CALOCUS) provides a framework for determining the clinically appropriate level of care for a child or adolescent in mental health treatment. With regard to risk of harm, the records support a score of 4. The patient has a serious risk of harm, due to substance abuse, including a recent overdose requiring hospitalization. In terms of functional status, the records support a score of 3. The documentation noted moderate functional impairment due to conflict with parents and social isolation due to substance use. The patient demonstrated recent gains or stabilization in functioning while participating in treatment in a structured, protected, and/or enriched service. With regard to comorbidity, the records support a score of 3. The patient had significant comorbidity, due to the presence of substance abuse, hallucinations, and a history of pancreatitis. In terms of level of stress of the recovery environment, the records support a score of 3. The patient had a moderately stressful environment due to the recent death of his grandmother, and his fathers illness and homelessness. With regard to level of support of the recovery environment, the records support a score of 2 due to his parents participation in treatment. In terms of resiliency and treatment history, the records support a score of 4. The patient had poor resiliency and/or response to treatment, as he overdosed while participating in a partial hospitalization program (PHP), and his symptoms of depression, anxiety, and cravings continued in residential treatment.With regard to treatment acceptance and engagement, the records support a score of 2. The patient was motived and participated in treatment.Thus, the patient has a total score of 21. In this case, the recommended level of care is medically monitored residence-based services, due to the serious risk of harm score of 4. This is consistent with the RTC level of care. Therefore, RTC services are 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 overturned.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

A 33-year-old female enrollee has requested for Botox therapy for treatment of her bilateral cervical dystonia.   Findings:  Two physician reviewers found that Botox is investigational, and not an FDA approved or standard treatment. Multiple studies performed for cervical myofascial pain have shown no significant improvement over placebo. This includes a Cochrane Database Systemic Review (Peloso, et al.). Thus, there is no persuasive evidence that Botox is likely to be more efficacious in this setting than standard therapies.
Appeal type: Medical Necessity
Decision: Overturned

A 40-year-old female enrollee with chronic myelogenous leukemia requested authorization and coverage of autologous T cell collection and storage. The Health Plan denied the request.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plans denial on the basis that the requested services are medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for automated evaluation of meibomian gland, with or without tear film imaging device. Findings:  Three physician reviewers found this patient had symptoms of dry eye and meibomian gland dysfunction. The medical literature demonstrates that eyelid heat pulsation with the LipiFlow device may be effective. However, studies to date are flawed in a number of important aspects. The controlled studies include relatively small numbers of patients and cross-over of treatment groups after short periods of time. Per the medical evidence, automated evaluation of meibomian gland, with or without tear film imaging device was not likely to have been superior over other available treatment options. 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 reviewers 1, 2 and 3 are board certified in ophthalmology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a 10-year-old male has requested speech therapy for the treatment of the enrollees autism and speech impairment. Findings:  The physician reviewer found that speech-language goals are educational in nature and should be part of this patients school program. While autism is clearly a medical diagnosis and many therapeutic interventions for the condition are considered medically necessary, it is also a condition that is addressed in school programming. The goals outlined in the patients evaluation are not addressing specific medical conditions associated with autism, but rather, the educational and rehabilitative needs of this patient.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 49-year-old female who was seen in May 2003 for a left foot/ankle injury. The patient noted weakness and problems with gait. The physical therapy plan of 8/25/03 notes the patient reported an inability to ambulate with her walker. In addition, edema of the right foot at the point of the fracture was noted. Per a physical therapy follow-up note of 10/8/03, the patient indicated she was doing a lot of walking with the walker. A note dated 10/15/03 indicates the patient was walking daily. The submitted physical therapy notes are not specific regarding range of motion, strength, and gait deficits, etc.A request has been made for reimbursement for physical therapy services received from 10/8/03 to 2/20/04. The Health Plan has denied this request on the basis that the therapy at issue was not medically necessary for treatment of the patients medical condition.The physical therapy notes provided include no objective data regarding strength, range of motion or improvements with physical therapy. The evaluation and follow-up notes do not give any specific information regarding the patients physical therapy evaluation or progress. Thus, there is not sufficient objective evidence to support the need for physical therapy for dates of service 10/8/03 through 2/20/04. Therefore, I have determined that the therapy at issue was not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

A fifty year-old male who has been diagnosed with prostate cancer is requesting authorization of proton beam radiation therapy through the non-Plan provider.Reviewers Findings:  The reviewing physician found that because the patients cancer volume is small, research indicates all forms of radiation therapy would be equally effective in irradiating the cancer and would have similar side effects. There is no evidence that proton beam therapy would be more beneficial for this patient than the treatments offered by the Health Plan.  The reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Edarbyclor (azilsartan-chlorthalidone). The records provided for review document that this patient has been treated with multiple medications for hypertension in the past. Aside from Edarbyclor, there is no report of treatment with any other angiotensin-receptor blocker (ARB) and thiazide combinations. Although the provider reported that Edarbyclor has managed the patients blood pressure, similar combinations on the Health Plans formulary with equivalent safety and efficacy are available for management of this patients condition. There is a lack of hypertension guidelines recommending one ARB medication over another for the management of isolated hypertension in the absence of heart failure or renal conditions. Although Edarbyclor is the only combination ARB and chlorthalidone medication available, there are similar alternative combinations using hydrochlorothiazide as the thiazide component that have been shown to provide a similar effect. Given these findings, the requested Edarbyclor (azilsartan-chlorthalidone) is not medically necessary for 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 subspecialty certification in cardiovascular disease and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Follistim AQ 300 IU cartridge (quantity of 8) and Menopur 75 IU vial (quantity of 8).The submitted records do not support that the medications at issue were medically necessary. The submitted records reflect that the patient had a progesterone level that was in the ovulatory range without treatment. Records reflect that the medications at issue were being taken electively to attempt to get embryos for a gestational carrier, and not for any apparent medical indication. There is no indication in the patients medical records that she is infertile, nor a medical reason specified for why the patient had decided to have another person carry her baby. There is also nothing to support the need for ovulation induction other than a planned egg retrieval. Under these circumstances, the medications Follistim AQ 300 IU cartridge (quantity of 8) and Menopur 75 IU vial (quantity of 8) were not medically necessary for the patients medical condition.Final Result: The reviewer determined that medications at issue were not medically necessary for the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in obstetrics and gynecology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Armour thyroid. According to medical literatures, 48.6% of patients preferred desiccated thyroid extract (DTE), such as Armour thyroid. In the subgroup analyses, those patients who preferred DTE, lost four pounds during the DTE treatment, and their subjective symptoms were significantly better while taking DTE as measured by the general health questionnaire-12 and thyroid symptom questionnaire. Similarly, researchers found a higher satisfaction rate in patients on DTE. According the researchers, clinical evidence is not sufficiently strong to support LT4/LT3 combination therapy in patients with hypothyroidism. Medical Literatures noted that providers should consider adding T3 as a therapeutic trial in selected patients. Overall, the data supports T3 therapy, either as liothyronine added to levothyroxine, or as DTE as an add-on or in lieu of LT4, as this patient is requesting, due to persistence of hypothyroid symptoms. Therefore, the records have established that the requested Armour thyroid 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 diabetes, endocrinology and metabolism 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 anesthesia services during an endoscopy for treatment of his medical condition. Findings:  The physician reviewer found that review of the submitted documentation fails to establish the medical necessity of the services at issue. The patient had a low ASA preoperative physical status classification score. Intravenous sedation performed by a non-anesthesiologist and non-certified registered nurse anesthetist is well supported in clinical practice given a low preoperative physical status classification score, such as in this case. Given the above, the services at issue were not medically necessary for treatment of the patients medical condition. 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 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: Upheld

A 21-year-old female enrollee has requested reimbursement for intensive outpatient program services over a one-month period for treatment of the enrollees mood disorder, not otherwise specified, cocaine dependence, alcohol dependence, post-traumatic stress disorder, and borderline personality disorder. Findings:  The physician reviewer found that the medical documentation provided on behalf of the patient fails to support the medical necessity for intensive outpatient program services.  The discharge summary from the residential treatment facility described her prognosis as fairly good and indicated the patient would be following up with her previous healthcare providers and residing in sober community housing.  There were no specific recommendations or arrangements for intensive outpatient program services upon discharge.  The notes from the intensive outpatient program facility lack an initial psychiatric assessment and treatment plan, which represent medical documents that justify particular treatment settings and interventions.  All told, intensive outpatient program services provided on the dates in question were not medically indicated in this patients case.
Appeal type: Experimental/Investigational
Decision: Overturned

A 43-year-old female enrollee has requested a PET/CT scan for an evaluation of her cervical cancer. Findings:  Three physician reviewers found that the use of PET/CT scans in the initial staging of cervical cancer is now covered under Medicare guidelines when used as an adjunct to conventional imaging (CT and/or MRI). This patient has extensive disease found outside the uterus. In order to properly plan treatment for this patient, the exact extent of this patients disease is needed. Studies have shown that the use of PET/CT scans for patients with cervical cancer is clinically relevant when the stage of disease is in question. PET/CT scan is medically indicated for this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

The parent of an 11-year-old male enrollee has requested the prescription medication Namenda for the treatment of the enrollees autism. Findings:  Two physician reviewers found that autism is a frequently seen condition without a known etiology. Namenda has been approved by the Food and Drug Administration for treatment of Alzheimers disease. Namenda is not approved for autism treatment. There is literature indicating its potential application in autistic treatment, but at this time the use of Namenda in this clinical setting remains unproven. At this time, there is insufficient data to support the use of Namenda for patients such as this patient.