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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for transcranial magnetic stimulation (TMS) services for treatment of the enrollees depression and anxiety. Findings:  The physician reviewer found that as noted in the current medical literature, TMS is a non-invasive brain stimulating procedure utilized in the treatment of major depressive disorder. The procedure is approved by the U.S. Food and Drug Administration (FDA) and tends to be very well tolerated with fewer barriers than electroconvulsive therapy. Further, the American Psychiatric Association (APA), investigated TMS and the available literature and concluded that TMS is appropriate for patients in the acute phase of treatment of major depressive disorder after failure of at least one antidepressant trial. Although this patient has had prior episodes of depression, the records do not describe any treatment for the most recent depressive episode prior. At that time, he was anxious and depressed with a constricted affect. He was started on sertraline, which is a selective serotonin reuptake inhibitor (SSRI) FDA approved for the treatment of major depressive disorder. The SSRIs are first-line medications for both depression and anxiety, and have a reassuring safety profile. However, they can take up to 12 weeks to reach maximal effect. Although sertraline is typically dosed between 100 and 200 mg daily, the patient showed signs of clinical improvement within four weeks from starting the medication. The patient was described as euthymic with logical thought processing and an appropriate affect in the absence of suicidality. Both the relatively conservative dose of 50 mg daily and prompt clinical response represented significant favorable prognostic indicators for the pharmacotherapeutic intervention. In sum, the documentation does not demonstrate failure of at least one anti-depressant medication during the episode of illness. Thus, based on current practice parameters, TMS services are not medically necessary. Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for inpatient level of care for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the services at issue. The services provided could not have reasonably been delivered effectively at a less restrictive setting. Outpatient treatment would have resulted in inadequate care.  Premature discharge of individuals with severe mental illness and prominent psychosis increases patient morbidity and the likelihood of prompt re-admission. The patient had a serious underlying formal thought disorder as evidenced in part by his multiple hospitalizations and previous treatment with clozapine, which is an antipsychotic typically reserved for the most challenging cases. Although the patient showed some signs of improvement, he remained psychotic and gravely disabled per the attending provider.  A conference call to discuss the conservatorship was arranged for the following day, at which time he remained gravely disabled due to his psychiatric illness.  The patient had a significant medication change with the addition of Depakote and the discontinuation of lithium. Thereafter, the patient continued to display delusional thinking, thought blocking, poor insight and an inability to care for himself due to his psychiatric illness. He remained engaged in active treatment, while the providers worked with the patient and the patients parent for treatment planning purposes.  Considering the severity of his illness burden, retaining this patient in the inpatient setting until conservatorship disposition and formalization of aftercare was medically indicated.  Further, during the disputed timeframe, the acute inpatient setting remained safe, clinically appropriate, and consistent with standard medical practice. As such, it was medically reasonably for the patient to remain at inpatient treatment center to both improve the patients condition and to prevent a more serious episode of illness. Final Result: The reviewer determined that the services at issue were medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 61-year-old female enrollee requested authorization and coverage of Humatrope. The Health Plan denied the request indicating that the requested therapy is not medically necessary for treatment of the enrollees growth hormone level.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: An  enrollee has requested reimbursement and prospective authorization and coverage for continued intensive outpatient program level of care. Findings:  The physician reviewer found that The submitted documentation fails to demonstrate the medical necessity of the services at issue.  The records indicate that the patient has remained sober throughout his treatment in the intensive outpatient program which he has consistently participated in for several months.  He has been cooperative, open and honest throughout treatment.  The records do not document severe psychiatric symptoms, and he has not been suicidal or homicidal during his time in the intensive outpatient program.  His medical problems appear to be under good control.  Based on the medical records, he could have been safely and effectively treated with outpatient services during the dates of service in dispute.  The clinical notes document motivation to change and a sustained period of sobriety.  There is a paucity of evidence to support superior benefit of intensive outpatient program level of care over outpatient treatment in this case.  All told, continued intensive outpatient program level of care  were not and are not medically indicated for the treatment of this patient. Final Result: The reviewer determined that the services at issue were not and 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 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for convergent ablation maze procedure (CPT 33266). The convergent atrial fibrillation ablation procedure is a combined minimally invasive, epicardial, surgical and endocardial catheter ablation. It is a newer procedure, and while there are some data supporting its use, further research and larger patient studies are needed to determine its efficacy and safety. DeLurgio and colleagues report that the hybrid convergent procedure had superior effectiveness compared to catheter ablation for the treatment of persistent and long-standing persistent atrial fibrillation; however, this conclusion was based on a small study of 149 patients. Therefore, a convergent ablation maze procedure (CPT 33266) is not likely to be more beneficial for treatment of the patients condition than any available standard therapy.Findings:  Two of the three physician reviewers found the requested convergent ablation maze procedure (CPT 33266) 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 service is 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 and 3 are board certified in internal medicine with sub-specialty certifications in cardiovascular disease and in clinical cardiac electrophysiology and are actively practicing. Physician reviewer 2 is board certified in internal medicine with sub-specialty certification in cardiovascular disease and is actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Orthovisc injections in both knees for three weeks. This patient presents with a history of chronic bilateral knee pain due to osteoarthritis. The provider noted that the patient is unable to take non-steroidal anti-inflammatory drugs (NSAIDs) due to a history of liver disease and topical NSAIDs cause a rash. Corticosteroid injections into the knees have been ineffective in relieving the patients knee pain. The patient has previously benefitted from viscosupplementation with Orthovisc injections in the past. Thus, the patients provider has recommended repeat viscosupplementation with Orthovisc injections series into both knees. A review of the medical record indicates that the last injections were approximately six months ago. 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 routine 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. In this case, the patient has a history of excellent relief from prior viscosupplementation. Furthermore, the patients remaining treatment options are limited. The patient has tried and failed multiple conservative treatments, with the alternative being bilateral total knee arthroplasties. All told, the requested Orthovisc injections in both knees for three weeks 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: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for (1) Xeljanz extended release 11 mg tablets and (2) Humira injector pen 40 mg/0.4 mL subcutaneous kit. Findings:  The physician reviewer found that  there are few therapies for the treatment of moderate-to-severe hidradenitis suppurativa (HS), Humira has been studied and approved by the U.S. Food and Drug Administration (FDA) for this indication. While the FDA recommended dosage is 40 mg weekly, Bouguen and colleagues note that adalimumab 80 mg weekly is well-tolerated and effective in the treatment of Crohns disease, indicating that 80 mg weekly is a safe dosage. Current medical literature includes several recently completed and ongoing clinical trials on the use of Janus kinase (JAK) inhibition for the treatment of HS. Alavi and colleagues report that JAK  inhibitors have been well tolerated, with observable response, and that the safety and efficacy findings from these studies support JAK1 inhibition in HS. Savage and colleagues report that the JAK inhibitor, tofacitinib, suppresses inflammatory cytokines implicated in HS pathogenesis, and may benefit patients with recalcitrant HS. In this case, the patient has severe HS, Hurley stage III, with significant pain affecting her quality of life. She has tried infliximab, Humira, oral antibiotics, topical clindamycin, and oral contraceptives. The records noted that her disease was not controlled on Humira 80 mg weekly monotherapy. Her disease has been controlled on the current medication regimen of Humira 80 mg weekly and Xeljanz 11 mg extended release daily for the past seven months. Given this patients response to her current regimen and the known action of these two agents and the biology of HS, the requested medication regimen is medically indicated. Therefore, (1) Xeljanz extended release 11 mg tablets and (2) Humira injector pen 40 mg/0.4 mL subcutaneous kit are medically necessary for the treatment of this patient.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 dermatlogy 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 has requested authorization and coverage for eight weeks of continued physical therapy. The records provided for review document that this patient has undergone extensive physical therapy for her medical condition. She has continued back, left foot and distal calf pain. The patient has already received extensive instruction on a home exercise program for her specific condition. The literature supports a multimodal approach to chronic pain with exercise and physical therapy as one component. However, for patients with chronic pain, extending physical therapy beyond three months is determined based on measurable objective clinical improvement. The documentation reviewed does not demonstrate that the patient requires the unique skills of a therapist for continued rehabilitation or that the patient has made objective gains to support an indication for additional physical therapy. The requested services are not part of a maintenance program, and the specialized skill, knowledge and judgment of a qualified therapist are not required to establish, design or deliver a program to maintain the patients current condition or to prevent or slow further deterioration. Accordingly, eight weeks of continued physical therapy is not medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in physical medicine and rehabilitation with subspecialty certification in neuromuscular 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: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Gamunex-C intravenous immunoglobulin (IVIG). The records provided for review document that this patient has Sjogrens syndrome per biopsy and symptoms of tachycardia, dizziness, and lightheadedness consistent with postural orthostatic tachycardia syndrome (POTS) (Blitshteyn). The patients symptoms were not substantially improved with metoprolol or diltiazem. The patients provider has recommended treatment with Gamunex-C IVIG. There are case studies in the peer-reviewed medical literature that demonstrate significant improvement in patients with POTS when treated with IVIG replacement therapy (Rodriguez, et al.). In addition, there is growing evidence to support that this type of dysautonomia may be immune mediated. Therefore, it is appropriate to provide a trial of IVIG for this patient and reassess in a few months to assess the degree of improvement in symptoms and to determine whether IVIG should be continued. For these reasons, the requested Gamunex-C IVIG 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 allergy and immunology 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for digital breast tomosynthesis for the enrollee, who presented for a breast examination. Findings:  Three physician reviewers found that the enrollee has a history of breast cancer. There was a lumpectomy performed on the left side. This study noted the breast tissue was average in density. There was stable postsurgical changes in the upper mid left breast. The impression was benign. The Health Plan has denied reimbursement for the digital breast tomosynthesis performed. Per the Health Plan, the service at issue was investigational for the evaluation of this patient. There is clinical support for the service at issue. According to a study, the use of mammography plus tomosynthesis in a screening environment resulted in a significantly higher cancer detection rate and enabled the detection of more invasive cancers.  Another study noted that integrated two dimensional and three dimensional mammography improves breast cancer detection and has the potential to reduce false positive recalls. Thus the literature supports the use of breast tomosynthesis over conventional mammogram due to improved cancer detection rate.  In sum, digital breast tomosynthesis performed was likely to have been more effective than other methods of evaluating this patient. Final Result: The reviewers determined that the service at issue was 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. 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

A 45-year-old female enrollee has requested reduction of nasal turbinates for treatment of her nasal polyposis.  Findings:  The physician reviewer found that there is no documentation in the submitted records of inferior nasal turbinate enlargement which would warrant a repeat procedure. Although the above-cited references indicate some benefit from turbinate reduction surgery, there must be some clinical reason documented for the performance of the procedure. In this case, the provided evidence does not demonstrate that appropriate indications for the procedure have been met. Such indications include hypertrophic turbinates, nasal obstruction/rhinorrhea and continued symptoms after at least six weeks of treatment with intranasal corticosteroid spray. None of these conditions has been shown to be present in this case. Thus, the requested reduction of the inferior nasal turbinates is not medically necessary because the procedure is not in accordance with generally accepted standard of medical practice in this setting.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 39-year-old woman with a body mass index (BMI) of 37. She has comorbid conditions including gastroesophageal reflux disease, hypertension, and degenerative disc disease. She has requested authorization for gastric bypass surgery. The Health Plan has denied the patients request. With a BMI of 37 and her comorbid conditions, the patient does not meet nationally accepted medical necessity criteria for consideration of weight loss surgery. There is potential that further attempts at conservative weight loss will be successful. Furthermore, as the patient has the potential for further weight loss through conservative means, the risks of weight loss surgery outweigh the potential benefits of the procedure. Therefore, I have determined that the requested procedure is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.