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

The patient is a 17-year-old male diagnosed with ADHD.  He was treated with Concerta, Adderall and Wellbutrin and appeared to respond well to the medications.  The patients mother noted that he became less tolerant of his medications after a time and she concluded that he had become depressed.  The patients parents believed that his depression was caused by the medications and that the medications were harmful to him.  The parents elected to discontinue the medications and seek alternative evaluation and treatment of the patients ADHD. The patient underwent a neurobehavioral evaluation that included an EEG and neuromuscular testing followed by neurofeedback treatments.  The Health Plan denied coverage and the family now requests reimbursement for the procedures.  It appears that the initial diagnosis of ADHD was accurate and the choice of medications appropriate. The patient responded in a positive manner as exemplified by the parents report of improvement in his academic performance. The severity of the later depressive symptoms is not known and no record of a psychiatric evaluation was submitted. Despite the informality of the diagnosis, the appearance of concurrent mood and attention deficit disorders is common. When depression is also diagnosed, an antidepressant medication can resolve the depressive symptoms in over 80% of the cases. On the other hand, without a psychiatric evaluation describing the nature of the depression and the severity of the patients symptoms, it is difficult to even validate this diagnosis. The decision to discontinue the medications appears to be one made by the parents because of their belief that the depression was caused by the medications and was harmful to their son.The literature documents the utilization of biofeedback in situations where stress is a factor such as: pilots, individuals who cannot take medication due to a neurological contraindication, stress reduction to improve blood pressure, etc. The utilization of biofeedback to decrease the symptoms of an attention deficit disorder is described in the literature as a secondary treatment if medication and/or behavior modification do not decrease the symptoms of ADHD. There is no reference in the literature to biofeedback as a treatment for clinical depression.  Neurofeedback would not appear to be the most appropriate treatment in this clinical situation. Additionally, in the absence of neurological findings suggesting neurological or neuromuscular dysfunction, there is no indication for an EEG or neuromuscular testing.  In summary, the procedures at issue are not the standard of care for the described symptoms and diagnoses of this patient. There are safe and effective treatments for ADHD and co-morbid depression. There is no documentation of the exploration of these services and the alternative evaluation/treatment chosen was not a medical necessity.  Therefore, I have determined the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

A 63-year-old female enrollee has requested transcranial magnetic stimulation (TMS) services for treatment of her major depressive disorder.  Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the services at issue.  There is sufficient support for the services at issue in this clinical setting.  TMS has been endorsed by the American Psychiatric Association in its current clinical practice guideline for the treatment of individuals with depression.  In this patients case, she was reportedly enduring an acute major depressive episode that caused significant morbidity and functional impairment.  She had pursued other standard therapies used to combat depression.  Considering the patients medical records, endorsement from the American Psychiatric Association and the expanding peer-reviewed literature base, TMS was an appropriate treatment in this patients case.  All told, transcranial magnetic stimulation (TMS) services provided from the time frame specified were medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: Anenrollee has requested authorization and coverage for Harvoni for eight weeks. Findings:  The physician reviewer found that According to 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, and advanced fibrosis is not required for treatment. Per the guidelines, treatment naive genotype 1 patients should be treated with Harvoni. Patients with viral loads less than 6,000,000 IU/mL can be treated for eight weeks. These guideline recommendations are based on multiple randomized clinical trials. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment . For these reasons, Harvoni for eight weeks is medically necessary for the treatment of this patients hepatitis C infection. Final Result: The reviewer determined that the requested medication regimen 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: An enrollee has requested authorization and coverage for Dupixent (dupliumab) injections. Atopic dermatitis (AD) is a common itchy inflammatory skin disease characterized by immune activation, marked epidermal hyperplasia, and defective barrier function, reflecting underlying alterations in keratinocyte differentiation. Much effort has recently been placed on the development of new treatment strategies for this increasingly common illness. Treatment of AD usually starts with topical agents, such as corticosteroids as well as phototherapy, including broad-band UVA (UVB-BB), UVA with psoralen, and UVA-1. More recently, narrow-band UVB has emerged as an effective treatment modality. Skin inflammation in atopic dermatitis results from inherited and acquired insults to the skin barrier, and agents that normalize the skin barrier reduce the dependence on topical steroids. Tacrolimus ointment and pimecrolimus cream are the topical calcineurin inhibitor approved for clinical use and has been demonstrated to be safe and effective in the treatment of patients with AD. Dupixent is a fully human Ig4 monoclonal antibody directed against the interleukin-4 receptor subunit a (IL-4Ra) of IL-4 and IL-13 receptors. Recent studies have all demonstrated how Dupixent can significantly reduce the molecular signature in the skin of patients with AD and significantly reduce the clinical manifestations of moderate to severe AD. It also significantly reduces the pruritus of moderate to severe AD, thus improving patients quality of life. Dupixent is administered by subcutaneous injection every other week. It was approved by the FDA in March 2017 for the treatment of moderate to severe AD.Althought the provider used the term `intrinsic allergic eczema` for the patients skin disease it is medically synonymous to atopic dermatitis. The patient has tried and failed multiple conservative treatments, including topical corticosteroids, phototherapy and several other topical agents. For this patient with atopic dermatitis, Dupixent injections represent a reasonable and evidence-backed next step in the plan to treat this patients condition. Therefore, the requested Dupixent injections are medically necessary for treatment of the patients condition.Final Result: The reviewer determined that the services at issue 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 dermatology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Sovaldi for treatment of her hepatitis C virus (HCV).  Findings:  Two physician reviewers found that Sovaldi (sofosbuvir) and ribavirin is medically necessary and is considered the standard of care for the treatment of the patients with HCV, genotype 3. In addition, treatment with Sovaldi is expected to be beneficial for this patient by potentially curing HCV infection and preventing further damage of the liver and progression of the disease process and development of cirrhosis and its potential complications. The combination therapy with Sovaldi and ribavirin has been approved by U.S. Food and Drug Administration (FDA). Therefore, the combination of sofosbuvir and ribavirin is medically necessary for this patient with HCV genotype 3. Final Result: Two reviewers 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 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: Medical Necessity
Decision: Upheld

The parent of a 16-year-old male enrollee has requested residential treatment for treatment of the enrollees polysubstance dependence.  Findings:  The physician reviewer found that based on the submitted documentation, the medical necessity for residential treatment level of care has not been established. Functional impairment that was severe is not evident, major risk of self-harm is not evident and severe co-morbidity is not evident. Based on American Academy of Child and Adolescent Psychiatry guidelines, residential treatment provided was not medically indicated.
Appeal type: Medical Necessity
Decision: Upheld

A 66-year-old female enrollee has requested bilateral breast magnetic resonance imaging (MRI) for an evaluation of her breast cancer. Findings:  The physician reviewer found that the recent peer-reviewed literature revealed no evidence to support screening breast MRI in patients with a personal history of breast cancer. In a study published in December 2007, Willey and Cocilovo state, Patients with an elevated risk, but not in the very high risk category, are those with a family history of breast cancer, personal history of breast cancer, significantly dense breast tissue.  Breast MRIs as a screening tool for patients at an elevated risk has not been scientifically proven to be of value. According to the American College of Radiology (ACR) guidelines as revised in 2008, there is insufficient evidence to support the use of screening breast MRI in patients with dense breast tissue and in those patients with a personal history of breast cancer. ACR guidelines state Breast MRI may be useful in women with a prior history of breast cancer and suspicion of recurrence when clinical, mammographic, and/or sonographic findings are inconclusive. This patient does not have any clinical or mammographic evidence of recurrent breast cancer. There is no family or personal history of BRCA gene mutation and there is no history of radiation to the chest as a child. Thus, the patient did not meet generally accepted criteria for a screening or diagnostic breast MRI.
Appeal type: Medical Necessity
Decision: Upheld

A 32-year-old male enrollee requested authorization and coverage of a new below the knee molded socket prosthesis.  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 services are not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Supartz injections (CPT 99213, 20610, and J7321) to the right knee. Evidence from systematic reviews and randomized controlled trials indicate that although viscosupplementation may relieve knee pain in some patients with osteoarthritis, data has not established which patients will benefit. Guidelines from the American Academy of Orthopedic Surgeons (AAOS) indicate that the data on safety and efficacy of viscosupplementation remain inconclusive. As such, the AAOS does not currently recommend viscosupplementation as standard treatment for osteoarthritis of the knees. Viscosupplementation is reserved for patients with a history of lasting benefit from prior injections and in cases where the remaining options are limited. This patient presents with a history of chronic right knee pain exacerbated by kneeling and squatting. The provider has documented the presence of osteoarthritis of the medial and lateral compartments and a degenerative tear of the medial meniscus on the magnetic resonance imaging (MRI) scan. Treatment has included non-steroidal anti-inflammatory drugs (NSAIDs) such as Relafen and Voltaren, a knee support, and a corticosteroid injection without significant benefit. In light of the degenerative changes, the provider is hesitant to perform arthroscopy. The provider instead recommended a trial of viscosupplementation prior to considering surgical intervention. Given the support in the medical literature, the requested Supartz injections (CPT 99213, 20610, and J7321) to the right knee are 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 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

A twenty year-old female with breast asymmetry is requesting coverage of a breast augmentation mammoplasty and bilateral periareola mastopexy.Reviewers Findings:  The reviewing physician found that the asymmetry was not of such a level that surgical correction was clinically indicated.  The reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a panniculectomy. The Health Plan has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees abdominal pannus and are not reconstructive in nature. Findings: The physician reviewer found that the requested services are medically necessary for treatment of the patients medical condition and are reconstructive in nature. Therefore, the Health Plans denial should be overturned. The patient has a significant lower abdominal pannus secondary to weight loss. The patient is noted to have functional impairment related to chronic intertrigo and chronic lower back pain associated with their overlapping lower abdominal skin and pannus. The patient's back pain has been treated conservatively with analgesics.  The patient's chronic intertrigo has been treated with over-the-counter creams, as well as prescription steroid and antifungal creams since May 2017. The patient's condition has affected their ability to ambulate. Photographs show evidence of a large, overlapping, abdominal pannus. The patient has evidence of chronic rashes that are directly related to the overlapping lower abdominal pannus and would be addressed with a panniculectomy. In addition, their chronic low back pain would likely improve with a panniculectomy. Therefore, the requested panniculectomy is medically necessary. Per the submitted documentation, this patients condition constitutes an abnormal structure of the body. The records document a large, overhanging pannus. The patients condition resulted from the treatment of obesity, which is a disease. The requested surgery is likely to improve the patients function. A panniculectomy is likely to improve their chronic rashes and back pain. Additionally, the requested services are likely to result in more than a minimal improvement in the appearance of the patient. Thus, the requested panniculectomy is reconstructive in nature. Credentials/Qualifications: The reviewer is board certified in plastic 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 parent of an eight-year-old male enrollee has requested for Genotropin injections for treatment of the enrollees long-term growth failure associated with idiopathic short stature. Findings:  The physician reviewer found that this patient is likely to represent a combination of familial short stature with eventually delayed puberty. No medical intervention is required in this setting as such patients are likely to achieve a normal adult height with respect to that of their family
Appeal type: Urgent Care
Decision: Overturned

An 18-year-old male enrollee has requested emergency services for the treatment of his medical condition.   Findings:  The physician reviewer found that this case involves the issue of whether a reasonable and prudent layperson in the patient's circumstances would belief he or she was experiencing an emergency medical condition.  An emergency medical condition means a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in any of the following: placing the patients health in serious jeopardy, serious impairment to bodily function, or serious dysfunction of any bodily organ or part. This patients medical problem met the prudent laypersons criteria for the need to seek emergent care. His moderate pain became severe pain, (reported as 8 of 10 on a 0 to 10 pain scale, where severe pain is defined as 7-10). Additionally, the patients pain was associated with bleeding from the back of the throat. Both severe pain and pharyngeal hemorrhage are signs and symptoms of an emergency medical problem that should be evaluated immediately. Thus, this patient had a medical problem that became acute; waiting hours to days to be seen elsewhere would not have been prudent.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested varicose vein heat therapy for treatment of her medical condition.   Findings: The physician reviewer found that the submitted documentation demonstrates the medical necessity of the requested services.  The medical records document a history of varicose veins.  The patients prior treatment has included leg elevation, nonsteroidal anti-inflammatory drugs (NSAIDs) to relieve discomfort, and compression stockings.  The records demonstrate that the patient is symptomatic, and she reports leg pain.  The current medical evidence supports the requested services in this clinical setting.  All told, the requested varicose vein heat therapy is medically indicated for the 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 vascular 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for continued inpatient treatment.Cellulitis is an infection of the deep dermis and subcutaneous tissue, presenting with expanding erythema, warmth, tenderness, and swelling. The diagnosis of cellulitis is based primarily on history and physical examination. The majority of cases of cellulitis are nonculturable and therefore the causative bacteria are unknown (Raff, A., and Kroshinsky, D.). Cellulitis is a frequent cause of hospital admission of adult patients (Collazos, J., et al.). In this case, the submitted documentation does not support that the patients request for continued inpatient treatment is medically necessary. The patient has been assessed and followed by Infectious Disease specialists, and there is no evidence of an abscess or deep soft tissue infection in the patients current records. A recent Infectious Disease note indicates that the patient was able to be discharged and no longer needed an acute level of care. At that point in time, the patient needed only outpatient follow-up and continued intravenous antibiotic therapy. These services may be provided in a skilled nursing facility or in a patients residence with nursing care assistance with the intravenous (IV) antibiotics. Under these circumstances, continued inpatient treatment is not medically necessary for the patients medical condition.Final Result: The reviewer determined that the requested services are not medically necessary for 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 infectious 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.