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

The parent of a 15-year-old female enrollee has requested partial hospitalization program services for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found that the services at issue were and are medically necessary for treatment of the patients medical condition. The progress notes show that the patient continued to have significant problems.  She was not compliant with her meal plan at the PHP, and was not compliant at home.  This was despite an inordinate amount of time that the parents spent supervising her meals and the time afterwards. She also indicated that she did not plan to continue to follow her meal plan after discharge. Furthermore, she continued to struggle with gender identity issues, anxiety and depression. She continued to receive therapy and an increased level of medication. She had passive suicidal ideation and struggled to avoid self-injurious behavior. According to the American Psychiatric Association (APA) guidelines for eating disorders, this patient continues to meet the criteria for PHP level of care services. By definition, she has only partial motivation to recover and needs structure to gain weight. Therefore, based on the medical literature cited above and the documentation submitted for review, the services at issue were and are medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of a 16-year-old male enrollee has requested authorization and coverage for magnetic resonance imaging (MRI) of the left knee for evaluation of the enrollees osteochondritis dissecans of the left knee. Findings:  The physician reviewer found that the current medical literature supports the medical necessity of MRI scans in decision making for juvenile osteochondritis dissecans of knees. According to Samora and colleagues, recent data suggest that MRI is the best method for analyzing the status of the cartilage and subchondral bone in patients with juvenile osteochondritis dissecans. The authors concluded that MRI continues to be reliably sensitive to juvenile osteochondritis dissecans lesions and is a good predictor of low-grade, stable lesions. Bauer and Polousky reported that treatment decisions in patients with osteochondritis dissecans should be based on MRI findings and not x-ray findings, although the diagnosis is made on x-ray findings. For these reasons, the requested MRI scan of the left knee is appropriate and medically necessary for decision making with regard to further treatment of this patients osteochondritis dissecans of the knee. Final Result: The reviewer determined that the requested service is 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 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

The patient has requested authorization and coverage for Rybelsus (semaglutide) 2 mg tablets, 30 quantity. The American Diabetes Association (ADA) guidelines support the use of a GLP-1 RA for patients with diabetes and cardiovascular disease in patients not reaching glycemic targets with use of non-GLP-1 RA oral agent regimens. Moreover, the ADA supports treatment with a GLP-1 RA with cardiovascular benefit for patients with comorbid arteriosclerotic cardiovascular disease. This patient has cardiovascular disease complicating his uncontrolled diabetes type 2. The advance in therapy to changing to Rybelsus in lieu of Tradjenta is appropriate to improve his diabetes control and decrease cardiovascular risk. Accordingly, the requested Rybelsus (semaglutide) 2 mg tablets, 30 quantity, is medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested medication quantity is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in internal medicine with subspecialty certification in diabetes, endocrinology, and metabolism and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for residential treatment center (RTC) services. The progress notes indicate the patient has been treated in an intensive outpatient program/partial hospitalization program (IOP/PHP). At the beginning of this program, he appeared to make some progress in treatment. The patient has shown a regression in his symptoms. He is experiencing passive suicidal ideation and has a history of a recent suicide attempt. He is engaging in substance use numerous times per week as well as other oppositional behaviors. He reports motivation to change his behaviors. However, he has made no significant changes behaviorally. He has continued depression that has affected his treatment. The records demonstrate that he has been unable to stay sober from substances at the current level of care. Applying the American Society of Addiction Medicine (ASAM) criteria for level of placement, this patient meets the threshold for RTC services. Although the patient does not meet all of the dimensional requirements, his presentation merits the increased monitoring and supervision provided at the RTC level of care. The patients records meets the requirements for dimensions 3 through 5. For dimension 3, emotional, behavioral or cognitive conditions, the patient continues to endorse passive suicidal ideation as well as depression. For dimension 4, readiness to change, the patient meets this criterion given his lack of motivation for change. For dimension 5, relapse, continued use, the patient has shown a lack of recognition of relapse triggers and continues to engage in substance use multiple times per week. Overall, the patients presentation meets the criteria for RTC level of care. Therefore, the requested RTC services are medically necessary for treatment of this patients behavioral health issues. 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 psychiatry with subspecialty certification in child and adolescent psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 23-year-old female enrollee requested authorization and coverage of participation in an inpatient pain management program. The Health Plan denied the request indicating that the requested services are not medically necessary for treatment of the enrollees chronic pain.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.
Appeal type: Experimental/Investigational
Decision: Overturned

A 49-year-old female enrollee has requested a spinal cord implant for treatment of her neck pain.  Findings:  Two physician reviewers found that spinal cord implant is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Spinal cord stimulation for chronic pain associated with cervical degenerative disc disease and post-laminectomy syndrome is supported in the peer-reviewed literature as safe and efficacious therapy. Taylor performed a systemic review and meta-analysis to determine the efficacy and safety of spinal cord stimulation in various types of pain including refractory neuropathic back pain. The results support the use of spinal cord stimulation in chronic back pain of neuropathic origin. Spinal cord stimulation was found to reduce pain, improve quality of life, reduce analgesic consumption and allowed some patients to return to work with minimal significant adverse events. Given the documentation submitted for review and the peer-reviewed literature cited above, the use of spinal cord implant in this clinical setting is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/ Case Summary:  The enrollee requested reimbursement for advanced lipoprotein laboratory testing.  She has a history of hyperlipidemia.  This testing does not have support from the national cardiovascular societies. The medical literature indicates the requested testing of LDL particle analysis, apolipoprotein B testing, and lipoprotein (a) testing are considered a matter of ongoing clinical investigation. They do not represent the standard of care for cardiovascular risk reduction, their results do not predict or rule out the possibility of acute cardiovascular events, such as heart attacks and strokes, and offer no proven clinical benefit over conventional lipid testing in the context of cardiovascular risk assessment. There is no established proven efficacy of these technologies, either in clinical trials to support their benefit compared to conventional cardiovascular risk assessment methods, as their use has not been conclusively linked to improved cardiovascular outcomes. Despite these tests having FDA approval, the enrollee does not stand to benefit from their use over conventional lipid testing and established risk assessment strategies. Final Result: Three of the three reviewers determined that the requested services are not likely to be more beneficial than any available standard therapy for treatment of the enrollees medical condition. Credentials/Qualifications: Three reviewers are board certified in Cardiovascular Disease 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: Experimental/Investigational
Decision: Upheld

Findings:  The physician reviewer found that An enrollee has requested authorization and coverage for IORT (intraoperative radiation treatment). There is a lack of support in current medical literature for the safety and efficacy of partial breast radiotherapy for the management of early stage breast cancer in patients under the age of 45. While Vaidya and colleagues report in a prospective, open-label, randomized controlled clinical trial with 2,298 patients that IORT during lumpectomy was an effective alternative to external beam radiotherapy (EBRT), trial selection criteria included being aged 45 years or older. In this case, given the relatively young age of this 42-year-old patient, and the use of IORT is not endorsed by expert consensus national guidelines. Rather, there is concern of a heightened risk of in-breast tumor recurrence with the use of IORT, as compared to standard, whole breast radiation therapy. Therefore, IORT is not likely to be more beneficial for treatment of the patients condition than any available standard therapy.Findings:  Three of the three physician reviewers found the requested IORT 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.
Appeal type: Experimental/Investigational
Decision: Upheld

A 54-year-old female enrollee has requested artificial cervical disc replacement surgery at spinal levels C4-5 and C6-7 for the treatment of her neck and arm symptoms. Findings:  Three physician reviewers found that although total artificial disc implantation is a novel technique to replace standard anterior cervical discectomy and fusion (ACDF) surgery, there is insufficient peer-reviewed evidence demonstrating its long-term safety, efficacy and adjacent level disease prevention. At this time, artificial disc replacement does not appear better than traditional ACDF for treatment of cervical disc disease and herniated cervical disc with radiculopathy.
Appeal type: Medical Necessity
Decision: Upheld

A fifty-three year-old obese female is requesting authorization for Xenical.  The patient had previously been treated with Xenical and experienced weight loss.  However, the patient had gained weight since discontinuing the medication.Reviewers Findings:  The reviewing physician found that there is no indication that prescription Xenical at a higher dose is indicated or necessary for this patient.  The reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Urgent Care
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested dermatology and related services on an emergent or urgent basis. Findings: The physician reviewer found that the submitted documentation demonstrates that a prudent layperson would not believe he was experiencing an emergency medical condition on the dates in dispute. Based on the records provided the patients presentation on the dates in dispute was not consistent with the above definition of an emergency medical condition. The patient presented for evaluation and treatment of psoriasis and vitiligo. Psoriasis is a chronic disease that can be associated with flares and remissions. In this case, the documentation submitted for review does not describe any symptoms of pain or indication he was suffering from a serious medical condition that was likely to place the patients health in serious jeopardy, cause serious impairment to body functions or cause serious dysfunction to a body organ or part. Thus, the services provided did not meet prudent layperson criteria for emergency care. Moreover, it has not been established that criteria for urgently needed services were met on the dates in dispute. The patient presented with psoriasis and vitiligo and was appropriately treated for these conditions. However, there is a lack of documentation supporting that the services at issue were necessary to prevent serious deterioration of the health of the patient for which treatment cannot be delayed until the he returned to the Plans service area. Based on the documentation submitted for review a prudent layperson in a similar situation would not have believed urgent medical attention was necessary to prevent serious deterioration of ones health. In sum, based on the patients clinical presentation on the patient did not meet prudent layperson criteria for urgently needed services.  Final Result: The reviewer determined that the patients symptoms did not meet prudent layperson criteria for emergency care or urgently needed services. Therefore, the Health Plans denial should be upheld.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: Upheld

The patients parent has requested authorization and coverage for visual communication analysis with self-determination theory. Researchers concluded that there is limited evidence that verbally based and ACC interventions improve spoken and non-verbal communication in minimally verbal children with ASD [autism spectrum disorder]. Based on the lack of evidence in peer-reviewed medical literature, there is insufficient support to demonstrate evidence of effectiveness for visual communication analysis with self-determination theory therapy. This patient has a diagnosis of ASD. The patient is being treated with applied behavioral analysis (ABA), which is considered the standard of care for their condition. All told, the requested visual communication analysis with self-determination theory 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 optometry and a certified optometric vision therapist 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

The parent of the enrollee is requesting authorization and coverage for male gender-affirming chest reconstruction surgery. The enrollee has gender dysphoria and is requesting transgender top surgery to achieve a more masculine-appearing chest. The enrollee has been on testosterone. His therapist indicates the enrollee meets the symptom criteria and diagnosis for gender dysphoria and has approval from his therapist to proceed with transgender top surgery. Criteria in the medical literature for mastectomy and creation of a male chest in female-to-male individual requires the enrollee to demonstrate the existence of persistent, well-documented gender dysphoria, the capacity to make a fully informed decision and to consent to treatment. Additionally, the individual must have attained the age of majority, and any significant medical or mental health concerns must be reasonably well controlled. The guidelines for chest surgery in adolescents indicate chest surgery can be carried out earlier, preferably after the individual has had ample time to live in the desired gender role and after one year of testosterone treatment. This allows the adolescent the opportunity to experience and socially adjust to a more masculine gender role before undergoing irreversible surgery. However, different approaches may be more suitable, depending upon the individuals specific clinical situation and goals for gender identity expression. The enrollee meets these guidelines.  He has well-documented gender dysphoria and has the capacity to make an informed decision. His anxiety due to his female chest appearance has exacerbated his gender dysphoria. Mental health concerns are managed by his therapist.  His psychologist has recommended the mastectomies. The standard of care for adolescent top surgery is met.Final Result: The reviewer determined that the requested service is medically necessary for the treatment of the enrollees medical condition. 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 similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

An enrollee has requested authorization and coverage for gene analysis. Testing for all five inherited thrombophilias is recommended in patients with deep vein thrombosis (DVT) under the age of 45. The prothrombin G20210A mutation is the second most common inherited thrombophilia after the factor V Leiden mutation. Testing for inherited hypercoagulability is recommended in patients with thrombosis at a young age, such as this patient, despite the provoked nature of her condition. Knowing whether this patient carries a mutation may not dictate duration of anticoagulation but will help determine her risk in situations that my increase her risk of a blood clot, such as pregnancy. Accordingly, the requested gene analysis is 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 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: Physician reviewer 1 is board certified in oncology with subspecialty certification in hematology and is actively practicing. Physician reviewer 2 is board certified in oncology and is actively practicing. Physician reviewer 3 is board certified in internal medicine with subspecialty certifications in medical oncology and hematology 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: Upheld

The patient is a 26-year-old woman with a body mass index (BMI) of 38. In addition, the patient has high cholesterol and back pain. She has requested authorization for gastric bypass surgery. The Health Plan has denied the patients request on the basis that gastric bypass surgery is not medically necessary for treatment of the patients medical condition.With a BMI of 38 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.
Appeal type: Medical Necessity
Decision: Upheld

A 61-year-old male enrollee requested tramadol ER 100 mg for medical treatment of the enrollees chronic pain status post bilateral hemi surgery and right hallux implant surgery.  Findings:  The physician reviewer found that tramadol ER 100 mg is not supported as medically necessary for treatment of this patients medical condition. The records indicate the patient has non-malignant chronic postsurgical pain. The current standard of care for chronic pain is treatment in a multidisciplinary practice to include physical therapy, massage therapy, cognitive behavioral therapy, and injections to help reduce pain.  Ballantyne and Mao reported that prolonged use of high dose opiates might induce tolerance, abnormal pain sensitivity, and hormonal effects. The aim of current guidelines is to protect patients from the adverse effects of opioid therapy. Therefore, it is in the patients best interest to wean off all opiates and participate in adjunctive therapy including non-narcotic medications, physical therapy, massage therapy, or cognitive behavioral therapy, in order to address chronic pain. Consistent with these findings, the requested tramadol ER 100 mg is not medically necessary.