Persius/imr-appeals huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Overturned

A 62-year-old female enrollee has requested hereditary non-polyposis colon cancer (HNPCC) testing for evaluation for possible HNPCC syndrome.  Findings:  Two physician reviewers found that by all definitions, the patient meets the Amsterdam criteria for testing for HNPCC. Enhanced screening of the patient secondary to a positive test result could result in an obvious benefit to the patient. HNPCC testing is the best available option to determine the patients risk and may significantly alter the patients clinical management depending upon the results.
Appeal type: Medical Necessity
Decision: Overturned

A 50-year-old female enrollee has requested adult psychiatric intensive outpatient program services for the treatment of her schizophrenia, post-traumatic stress disorder and bipolar disorder. Findings:  The physician reviewer found that the submitted clinical evidence demonstrates that the patient had just begun to show some progress in the IOP. The patients current symptoms are described as a recurrence of command auditory hallucinations, anxiety, paranoid ideation, and suicidal ideation. The patients treating psychiatrist has documented the patients compliance with treatment, her current compromised level of functioning, and the presence of a carefully thought out treatment plan with clear goals. The patient continues to experience flashbacks and nightmares in addition to concern about hurting herself or others. Given the patients well documented symptomatology, she meets clinical indications for continued treatment in the IOP program at this time.
Appeal type: Medical Necessity
Decision: Upheld

A 60-year-old female enrollee requested authorization and coverage for physical therapy. The health plan has denied this request indicating that the requested therapy is not medically necessary for treatment of the enrollees adhesive capsulitis of the left shoulder.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the health plans denial on the basis that the requested therapy is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a continuous glucose monitor (CGM). CGM detects glucose variations, time in glycemic target, and time in hypoglycemia. These metrics have been shown to enhance a patients self-management of diabetes. In a study by Ida and colleagues aimed to investigate the effects of CGM devices in patients with type 2 diabetes mellitus, the authors found that the CGM group exhibited significantly lower HbA1c levels and spent less time with hypoglycemia. This patients records indicate that he has a diagnosis of diabetes of recent onset. However, there is a lack of documentation of a thorough evaluation and discussion on the goals of therapy with his primary care provider or nutritionist. According to the American Diabetes Association, a comprehensive medical evaluation includes initial and follow-up evaluations, assessment of complications, psychosocial assessment, management of comorbid conditions, and engagement of the patient throughout the process. In the absence of this documentation, a CGM is not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested equipment is not medically necessary for evaluation 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 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: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for magnetic resonance imaging (MRI) of the lumbar spine. The American College of Radiology (ACR) appropriateness criteria note that an MRI of the lumbar spine is usually appropriate for patients with subacute or chronic low back pain, with or without radiculopathy, who are candidates for surgery or intervention and who have persistent or progressive symptoms during or following six weeks of optimal medical management. Given that an MRI of the lumbar spine is strongly recommended in patients with persistent low back pain with neurologic symptoms to evaluate for a surgically correctable cause, such as a mass or herniated disk, and for consideration of surgery or an epidural steroid injection, the requested service is medically indicated. Therefore, an MRI of the lumbar spine is medically necessary for the evaluation of this patient.Final Result: The reviewer determined that the requested service 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 diagnostic radiology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 59-year-old male enrollee has requested Avastin injections for treatment of his diabetic retinopathy. Findings:  The physician reviewer found that vascular endothelial growth factor (VEGF), if present in the retina, produces angiogenesis and increased vascular permeability. This can have very serious effects on visual function. The level of VEGF is increased in the retina in patients with proliferative diabetic retinopathy. Anti-VEGF drugs negate this effect to a very significant degree. There are numerous articles documenting the successful treatment of proliferative retinopathy with intraocular Avastin. Avastin injections can be an appropriate and efficacious treatment in patients who present with resistant retinal neo-vascularization, despite repeated laser therapy, in that the cascade of severe ischemia, poor circulation and massive neo-vascularization can be averted. Arevalo and colleagues found that Avastin resulted in marked regression of retinal neo-vascularization in proliferative retinopathy. Mason and colleagues also found that Avastin was an excellent treatment when given before panretinal laser therapy. Spaide and Fisher felt that Avastin injections in patients with proliferative retinopathy and vitreous hemorrhaging resulted in regression of the neo-vascularization, and a clearing of the vitreous hemorrhage. This patient was essentially blind in the OD, with severe proliferative retinopathy in the OS and with vitreous hemorrhaging. The patient had panretinal laser therapy previously, but still had neo-vascularization in the OS. The prior Avastin injections resulted in improvement of his vision, and the clearing of the vitreous hemorrhage. Avastin therapy has become the standard of care in the treatment of neo-vascularization associated with proliferative diabetic retinopathy. This is particularly true when other forms of therapy have failed as is the case with this patient.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested breast tomosynthesis for evaluation of her medical condition.  Three physician reviewers found that in this patients case, the services at issue were likely to have been superior over other available modalities.  The addition of breast tomosynthesis to screening mammography has been associated with a decreased call back rate and increased detection of small cancers.  Thus, there is support for the addition of breast tomosynthesis to digital screening mammography views in this clinical setting.  All told, the records support the superior efficacy of breast tomosynthesis.  Final Result: Three reviewers determined that the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: All three reviewers are board certified in diagnostic radiology 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

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Acthar Gel for treatment of her medical condition.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication.  The patient has been recently switched to a new medication regimen.  The medical records document significant improvement in pain and stiffness on the current regimen.  There is literature against the use of long-term corticosteroids in rheumatoid arthritis.  When corticosteroids are used for a period of one month or less, they are more effective than either placebo or a nonsteroidal anti-inflammatory drug.  Although Acthar is approved for flares in rheumatoid arthritis, there is a lack of evidence in the literature supporting its use over other corticosteroids.  In this case, the medical records fail to document the medical necessity of the requested Acthar Gel. 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 sub-specialty certification in rheumatology 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: Upheld

A 47-year-old male enrollee requested authorization and coverage of compounded verapamil for the treatment of peyronies disease.  The health plan denied the enrollees request indicating that the requested treatment is experimental.Three physician reviewers performed an experimental/investigational Independent Medical Review.  Each of the three physician reviewers concluded that compounded verapamil is not likely to be more beneficial for treatment of the enrollees peyronies disease than any available standard therapy.  Because all three physician reviewers concluded that the requested treatment is not likely to be more beneficial for treatment of the enrollees medical condition than any available standard therapy, the review organization upheld the health plans denial.
Appeal type: Medical Necessity
Decision: Upheld

A female enrollee requested head magnetic resonance imaging (MRI) and abdominal MRI for medical evaluation of her medical condition.  Findings:  The physician reviewer found that the patient has no history of malignancy, abnormal physical examination or other indications for an abdominal MRI.  Based upon current guidelines, MRI of the brain may be indicated when there is a history of blurred vision with headache but only after a detailed and complete neurological evaluation.  All told, the requested head MRI and abdominal MRI are not medically indicated for the evaluation of this patient.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a five-year-old female enrollee has requested partial hospitalization program (PHP) services for treatment of the enrollees autism. Findings:  The physician reviewer found that the medical records indicates that the patients symptoms improved while participating in the ECPHP. The weekly progress note on the date specified indicates that the patient participated in social recreation with good attention and compliance and also notes that the patient had good interest in a new classroom peer, displayed good response to limits and displayed safe behavior. Other progress notes indicated there were no tantrum behaviors from the time period specified. A progress note indicates the patients performance in structured activity was fair to good and her ability to initiate contact with peers and adults was described as good. An additional progress note described that the patients anxious behavior was responsive to positive reinforcement and redirection and her engagement in unsafe behavior was noted to be at 30%. The medical records also indicate the patient displayed safe behavior and that her anxiety and social interactions were improved overall. In sum, the patients behaviors had improved throughout the course of her treatment in the ECPHP program and she could have been transitioned to a lower level of care from the date indicated and forward. Therefore, the Health Plans denial was appropriate.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a 17-year-old female enrollee has requested continued residential level care for the treatment of the enrollees behavioral health issues. Findings:  The physician reviewer found that the medical records indicate that at the time of admission the patient was medically stable and exhibited no self-harm behavior. She was described as well developed and well nourished with no medical issues related to an eating disorder. She was noted to be without suicidal or homicidal ideation. The provider indicated that the patient made progress while being treated in a wilderness program prior to this residential treatment admission. Progress notes by the provider reflect issues related to trichotillomania and anxiety. The notes indicate the patient was working on self esteem issues and she was anxious but not sad. The provider notes that the patient was sleeping well, anxious and pulling her hair less. There were medication adjustments to address anxiety and hair pulling including Prozac, Zoloft, Neurontin and n-acetyl cysteine. The records reflect no documentation of binging, purging or restrictive eating. The patient was participating in family therapy and group therapy in a cooperative manner and was compliant with medication adjustments. Therefore, the need for 24-hour residential level of care is not supported by the medical documentation. Based on American Academy of Child and Adolescent Psychiatry (AACAP) and American Psychiatric Association (APA), treatment guidelines as well as Child and Adolescent Level of Care Utilization System (CALOCUS) guidelines, this patient was appropriate for transfer to a less restrictive level of care.
Appeal type: Medical Necessity
Decision: Upheld

A 20-year-old male enrollee has requested a prosthetic running limb for treatment of his status post an above-the-knee amputation.  Findings:  The physician reviewer found that this patient has goals of competing in the 2012 Paralympics, and he has requested a prosthetic running limb. Prostheses for running are specially adapted for this task.  However, these adaptations are not necessary for an individual to accomplish basic mobility-related activities of daily living. The patient currently uses a prosthesis that allows him to accomplish his mobility-related activities of daily living, including community mobility. The requested equipment adds to the patients options for exercise and recreation, but it is not medically necessary.  The submitted medical records do not demonstrate the medical necessity of the requested equipment.  All told, the requested prosthetic running limb is not medically indicated.
Appeal type: Medical Necessity
Decision: Overturned

The parent of an 18-year-old male enrollee has requested sub-acute residential psychiatric treatment for the treatment of the enrollees behavioral health problems. Findings:  The physician reviewer found that the medical documentation supports the medical necessity for sub-acute residential psychiatric treatment in that: there was a deterioration in his level of functioning, with increased depression and impaired social functioning; there was evidence of his inability to be managed at a lower level of care; there was a need for mood stabilization and close monitoring of  his medications as they were adjusted; there were medical concerns with his medication adjustments such as the occurrence of  seizure-like episodes, which  required neurological evaluation including a magnetic resonance imaging scan and electroencephalogram and; there was concern about  hypomanic episodes as medication adjustments were initiated which required close monitoring. The provided sub-acute residential level of care for this patient was consistent with Child and Adolescent Level of Care Utilization System (CALOCUS) placement criteria and his treatment interventions were consistent with practice parameter guidelines.
Appeal type: Medical Necessity
Decision: Upheld

A 57-year-old female enrollee has requested psychotherapy treatments at a frequency of one time per week (rather than the authorized one time per month) and continued weekly psychotherapy for treatment of her major depression, recurrent, moderate, post-traumatic stress disorder from childhood and history of anorexia nervosa in adolescence, currently in remission.  Findings:  The physician reviewer found that there is no evidence of acute decompensation warranting inpatient treatments. Additionally, there is no evidence of acute/continuation/maintenance strategies previously employed other than psychotherapy. In this patients case, the treatment goals identified include prevention of increase in anger and depressive feelings and providing emotional support in the context of this patient being isolated. These goals do not warrant the frequency and duration of the psychotherapy sessions requested. The treatment plan does not reflect any current or planned coordination with available community or peer support services. Ongoing weekly psychotherapy sessions are not likely to support progress towards recovery. The medical literature supports the efficacy of psychotherapy in the treatment of major depressive disorder. However, the patient can be effectively treated with psychotherapy treatments at a frequency of one time per month. As noted in the study by Frank and colleagues, monthly psychotherapy sessions were sufficient to prevent depression relapse/recurrence. All told, psychotherapy treatments provided from the said date onward at a frequency of one time per week (rather than the authorized one time per month) and continued weekly psychotherapy treatments were not and are not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

A 36-year-old male is requesting partial hospitalization services for the treatment of chemical dependency.  Findings:  The physician reviewer found that during the specified date he needed the structure, supervision and psychological intervention provided in a partial hospital program. The submitted evidence demonstrates the patient did require partial hospital treatment through the specified date.
Appeal type: Experimental/Investigational
Decision: Upheld

A 40-year-old female enrollee has requested a magnetic resonance (MR) neurography for evaluation of her sciatica, buttock and leg pain.  Findings:  Two physician reviewers found that a literature search revealed a paucity of data establishing the sensitivity and specificity of MR neurography as a diagnostic test for piriformis syndrome. Filler and colleagues reported that in 239 patients with sciatica in whom standard diagnosis and treatment failed to provide improvement, MR neurography and interventional MR imaging led to the re-diagnoses. In their conclusion, the authors stated that MR neurography has 93% specificity and 64% sensitivity in distinguishing patients with piriformis syndrome from those without. In a critique of this paper, Tiel and Kline pointed out that sensitivity and specificity are used in clinical studies to evaluate new methods in reference to a recognized gold standard. Piriformis syndrome has not been submitted to this standard, and the data that the authors present are misleading. Comparing the two chosen groups may be interesting and illustrative, but in no recognized way does such a comparison generate a valid sensitivity or specificity. In a separate critique, Tiel stated that, MR neurography as practiced by Filler (and colleagues) needs histologic and physiologic confirmation to support his findings concerning the diagnosis of entrapment of the sciatic nerve by the piriformis muscle. Based on the lack of evidence for the true sensitivity and specificity of MR neurography for the diagnosis of piriformis syndrome, MR neurography was not likely to be more beneficial for evaluation of this patients medical condition than any available conventional modality when performed on the date in question.
Appeal type: Medical Necessity
Decision: Upheld

A 61-year-old male enrollee has requested weekly outpatient psychotherapy for treatment of his anxiety disorder, not otherwise specified.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  In general, current practice is focused on aggressive treatment of anxiety and suicidality, particularly in the acute phase of illness, followed by less frequent services in the maintenance phase to foster autonomy and recovery.  In this patients case, there is an absence of a comprehensive psychiatric assessment and longitudinal documentation, including developmental history, treatment history, quantifiable goals with objectives to achieve said goals, barriers to progress, multidisciplinary contributions, physical examination, and supportive community interventions.  Thus, the records do not demonstrate that weekly treatment is having a positive effect in bolstering autonomy and resiliency while mobilizing the patient towards remission.  Although the patient remains symptomatic, there is a lack of evidence of specific functional impairment, grave disability, or imminent threat due to chronic suicidality or persistent excessive anxiety burden.  Thus, weekly outpatient psychotherapy from the said date forward was not and is not medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

A forty-nine year-old male with hyperlipidemia, cardiac asthma, and chest pain is requesting coverage for a CT angiography.Reviewers Findings:The three reviewing physicians have found that the diagnostic procedure at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.  The physicians found that the Health Plan denial should be upheld.