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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for transcranial magnetic stimulation (TMS).Findings:  The physician reviewer found that patients sustaining mild traumatic brain injuries often report a constellation of physical, cognitive, and emotional symptoms referred to as post-concussion symptoms. The most commonly reported post-concussion symptoms are headache, dizziness, difficulty with memory and concentration, irritability, and depression. The current treatments for post-concussion syndrome include medications, cognitive rehabilitation, psychotherapy, and interdisciplinary collaboration with physical, occupational, and speech therapies. A few studies have considered applying repetitive TMS as a treatment for post-concussion syndrome. Moussavi and colleagues conducted a randomized double-blind study investigating the effect of repetitive TMS on persistent post-concussion syndrome. The authors found that repetitive TMS is a tolerable and potentially effective treatment option for patients within one year of concussion. Koski and colleagues tested the safety, tolerability, and efficacy of repetitive TMS for post-concussion syndrome. The authors concluded that repetitive TMS is safe and well tolerated, which supports additional studies with randomized controlled trials. In this case, the patient presented to the provider with post-concussion syndrome that started at least two years prior. Based on current data, the patients injury occurred more than one year prior to TMS treatment.  Accordingly, the TMS provided was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings:  Two of the three physician reviewers found the TMS provided was 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 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 neurology 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: Experimental/Investigational
Decision: Upheld

A female enrollee requested the Zio Patch for medical evaluation of her premature ventricular complexes (PVCs).  Findings:  Two physician reviewers found that currently, there is a lack of randomized clinical trial data addressing the Zio Patch for PVC quantification. As this patient had a sensation of single skipped beats, and had previously been documented to have PVCs on monitoring and on treadmill testing, it was suspected that she had PVCs. Thus, the monitor was being used to quantify the PVC burden. It is not established that the Zio Patch is more effective than a standard 24-hour Holter monitoring for quantification of PVCs. Accordingly, the Zio Patch at issue was not likely to have been more beneficial for evaluation of this patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: A male enrollee has requested reimbursement for residential treatment center services. The Health Plan has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees alcohol abuse and depression.At issue in this case is whether the requested residential treatment center services were medically necessary for treatment of the patients behavioral health condition.The American Society of Addiction Medicine (ASAM) 2013 guidelines for residential treatment evaluates patient status along six dimensions including acute intoxication; other biomedical conditions; emotional/behavioral/cognitive functions; readiness to change; relapse/continued use potential; and recovery environment. To be eligible for residential treatment care, the patient must meet all six criteria.Documentation provided for this review indicates that the patient was in mild withdrawal although no clinical institute withdrawal assessment (CIWA) scores were provided. He did not have a biomedical condition that would interfere with treatment and was deemed to be medically stable. He was able to participate in therapy, and noted to not have significant functional defects or impulse control. By medical records, he is a recidivist to treatment and was likely to relapse. He was noted to be motivated to change. By this evaluation, this patient did not meet all six ASAM criteria (did not meet emotional/cognitive and biomedical condition requirements) and therefore was not eligible for residential treatment facility. Therefore, the residential treatment services at issue were not medically necessary.Final Result: The reviewer determined that the services at issue were not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for magnetic resonance imaging (MRI) of the lumbar spine. The submitted documentation supports the medical necessity of the requested services. The first appropriate imaging for the evaluation of low back pain with radicular symptoms are lumbar radiographs. According to the American College of Radiology, if the pain persists after four to six weeks of conservative management, and the patient is a surgical or intervention candidate, then MRI of the lumbar spine is the usually the appropriate examination. This patient has had low back pain with associated right radiculopathy symptoms. She failed conservative management, including physical therapy, chiropractic therapy and corticosteroid injection. MRI of the lumbar spine could change the patients management, which may include surgical intervention. Therefore, the requested MRI of the lumbar spine is medically necessary for the evaluation of this patient.Final Result: The reviewer determined that the requested services are medically necessary for evaluation 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the DecisionDx-Melanoma gene assay. The Health Plan has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees medical condition.Findings: The National Comprehensive Cancer Network guidelines indicate while there is interest in newer prognostic molecular techniques, such as gene expression profiling, to differentiate melanomas at low versus high risk for metastasis, routine prognostic genetic testing of primary cutaneous melanomas is not recommended outside of a clinical study. The records of this testing is not likely to alter treatment and surveillance recommendations. As such, DecisionDx-Melanoma gene assay was not likely to have been of greater benefit than any available standard therapy of evaluating this patients medical condition.Final Result: All three reviewers determined that the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: All three reviewers are board certified in internal medicine with sub-specialty certification in medical oncology 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 reimbursement for residential treatment center services for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found that There is a lack of a support for the medical necessity of the services at issue in this clinical setting. The patient was admitted to the residential treatment center services with a weight of 129 pounds. The record noted that her ideal body weight (IBW) was 112.5 pounds, so her admission weight was 114% of her IBW. The patient has chronic suicidal ideation and has a history of seven suicide attempts. Her last self-injury was in April 2017. The patient had passive suicidal ideation with no intent or plan. She was medically stable and did not require 24 hour observation. The records do not indicate that the patient was medically compromised. The medical evidence indicates that inpatient treatment does not provide advantages over outpatient management. It is the standard of care to treat patients in the least restrictive environment possible. The patient had an IBW of 114% and could have been treated at a lower level of care, such as a partial hospitalization program. Therefore, RTC services were not medically necessary for the treatment of this patients medical condition.  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: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential treatment. Findings:  The physician reviewer found that the submitted records fail to demonstrate the medical necessity of the services at issue.  There was no evidence of suicidality or homicidality. She was medically and psychiatrically stable.  There were no emotional, behavioral, cognitive, or impulsive symptoms that would warrant this level of care.  She had no history of treatment at a lower level of care.  There was no evidence of a high-degree of impulsivity, agitation, depression, mania, hallucinations, or any other significant symptom that would interfere with her care.  She was motivated and appeared to be working the program.  She had a stable and sober living environment.  She no longer required the structure of a residential setting and could have continued treatment on an ambulatory level of care, such as intensive outpatient program level of care.  All told, residential treatment provided was not medically indicated for the treatment of this patient. Final Result: The reviewer determined that the services at issue were not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The physician 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

The parent of a three-year-old female enrollee has requested  speech evaluation and treatment up to two times per week for treatment of the enrollees global motor developmental delays. Findings:  The physician reviewer found that the submitted documentation does not establish the medical necessity of the requested services. The submitted clinical reports include a brief letter of medical necessity from the therapist and a prescription from the physician with no listed diagnosis. Upon review of the medical literature for hemihypertrophy and cafe au lait spots, there is no correlation between speech delays and hemihypertrophy. However, there is literature supporting the presence of language and speech delays in children with neurofibromatosis type 1. Cafe au lait spots may be an indicator of neurofibromatosis type 1, depending on the number and size of the spots. The submitted medical record documentation does not demonstrate that a diagnosis of neurofibromatosis type 1 has either been confirmed or ruled out. Given the absence of evidence of an underlying medical diagnosis and the lack of recent objective evaluations, the medical necessity of the proposed therapy has not been demonstrated.
Appeal type: Experimental/Investigational
Decision: Overturned

A 47-year-old female enrollee has requested Botox injections for treatment of her migraine headaches.  Findings:  Two physician reviewers found that the patient has been diagnosed with intractable migraine, and tried and failed prior preventives. Her headache frequency is noted to be fewer than 15 headache days per month, which fits the diagnosis of high frequency episodic migraine. To date, the use of Botox for treatment of patients with episodic migraine has not shown consistent benefit, although a trend for positive outcomes has been seen in treatment of patients with 10-14 headache days monthly. In the clinical studies, Botox has been evaluated in phase 3 trials in patients who were not on other preventives. The patients were treated with 155-195 Units and showed statistical and clinical benefits in terms of reduction in the number of headache days in comparison to placebo. Based on 2 phase 3 trials, the Food and Drug Administration (FDA) has approved Botox for chronic migraine preventive therapy at 155 IU dosing. Given that Botox has been demonstrated to offer benefits in patients with the worst migraine patterns, its use in other migraine patients who have failed other preventives is also likely to provide relief of symptoms. Therefore, Botox should be approved for this patient as it is likely to be more beneficial for treatment of this patients migraines than any standard alternative.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential level of care. Findings:  The physician reviewer found that, although chemical dependency services were indicated based on the records provided, the records do not document the medical necessity of residential level of care. The patient was discharged from a detoxification facility.  She was motivated for treatment.  She was psychiatrically stable.  She had safe and sober housing.  She had no history of local treatment and was not engaged in clinical services during the episode of illness.  Thus, there was no evidence that a less restrictive setting, following a successful detoxification, would have been unsafe or inadequate at the time. However, intensive outpatient programming was and is medically necessary in this case.  The patients addictive illness was central to her daily routine and contributed to significant impairment across multiple domains of functionality.  Despite occupational discord, relationship struggles, and two prior treatment attempts, the patient was unable to achieve significant periods of sobriety.  This patient had not consolidated treatment gains during a brief admission for detoxification.  Thus, intensive outpatient program treatment was and is reasonably expected to improve the patients condition and prevent a more serious episode of illness via relapse.  In sum, residential level of care was not medically indicated.  However, intensive outpatient program level of care from (30-day treatment program) was and is medically indicated for the treatment of this patient. Final Result: The reviewer determined that a portion of the services at issue was and is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned. Credentials/Qualifications: The physician 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

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Harvoni for 12 weeks for treatment of his hepatitis C virus. Findings: The physician reviewer found that per 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. The guidelines report that patients with cirrhosis are highest priority for therapy. Per the guidelines, cirrhotic genotype 1 patients who have failed interferon-based therapy should be treated with Harvoni for 24 weeks rather than 12 weeks; these guideline recommendations are based on multiple randomized clinical trials. Additionally, the guidelines report that patients with creatinine clearance below 30 mL/min should not be treated with Harvoni  alternative therapies are recommended instead. For these reasons, the requested treatment with Harvoni for 12 weeks is not supported as medically necessary for the treatment of this patients hepatitis C infection.  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 physician 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for hydrogen breath test (CPT code 91065). Based on the clinical information provided, this patient presents with symptoms of abdominal pain, nausea, and constipation. Physical examination and radiographic imaging confirmed constipation. Previously, the patient experienced improvement with Senna therapy, but this has become less effective. The patient does not have risk factors to predispose her for small intestinal bacterial overgrowth (SIBO) such as gastrointestinal surgery or underlying condition such as anatomic abnormality, small bowel dysmotility, abnormal communication between proximal and distal gastrointestinal tract, or other systemic condition. Given the patients symptoms, testing for hydrogen breath test is not likely to improve the patients health outcome when compared to use of standard medical therapies for constipation and irritable bowel syndrome as supported by well-designed randomized controlled trials. In summary, the requested hydrogen breath test (CPT code 91065) is not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Findings:  Two of the three physician reviewers found the requested hydrogen breath test (CPT code 91065) is not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested services are not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewers 1, 2, and 3 are board certified in internal medicine with subspecialty certification in gastroenterology 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: Overturned

An enrollee has requested authorization and coverage for lap band removal surgery and gastric bypass revision surgery to be performed at the same time.The requested gastric bypass revision surgery is not supported in this clinical setting. There are no anatomic complications or improvements reported in the patients records to warrant any revision of the patients gastric bypass. Normal anatomy is documented and this cannot be removed. Further distalization of the gastric bypass is not a standard procedure and would be considered investigational at this time. Accordingly, gastric bypass revision surgery is not medically necessary to treat the patients medical condition.The submitted documentation supports the medical necessity of lap band removal surgery. The patient has epigastric pain that is secondary to the port of the lap band. This is a foreign body and it cannot be improved without surgical removal. The patient also has nausea, and this may also be related to the lap band. Lap band deflation would not impact the port, and if the patient is enduring chronic epigastric pain related to the port, it can only be corrected by removal. Lap band and port removal are reasonable and medically necessary, as medical treatment is not possible given that it is a foreign body. Under these circumstances, lap band removal surgery is medically necessary to treat the patients medical condition.Final Result: The reviewer determined that a portion of the requested services is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned.Credentials/Qualifications: The reviewer is board certified in 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.