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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for the skilled nursing facility (SNF) services provided treatment of the enrollees sepsis, pneumonia, non-ST elevation myocardial infarction (STEMI), and other abnormalities of gait and mobility.Findings: The physician reviewer found that the documentation does not reveal that the patient has needs for SNF services. The patient does not have intravenous (IV) antibiotics, complex wound care needs and does not require daily inpatient SNF services to prevent a deterioration in his condition or establish an effective home program. The documentation does not report that the patient requires inpatient skilled therapy services on a daily basis or skilled nursing services on a daily basis. The records indicate that the patient has plateaued in therapy and therefore would not be expected to make measurable gains in a reasonable and predictable time or require daily inpatient skilled therapy to prevent a deterioration with mobility, ADLs, or to establish an effective maintenance program. The patients needs can safely and adequately addressed with physical therapy with home health services. The patient does not require continued services on an inpatient treatment and physical therapy at a SNF level of care. Given these findings, the SNF services provided (including physical therapy) were not and are not medically necessary for 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 physical medicine and rehabilitation with sub-specialty 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: Upheld

The parents of a 6-year-old female enrollee requested authorization and coverage of speech therapy for the treatment of a severe delay in language skills.  The Health Plan denied the enrollees request indicating that the requested treatment is not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer upheld the health plans denial on the basis that the requested services are not medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Urolift cystoscopy for treatment of the enrollees benign prostatic hyperplasia. Findings: All three physician reviewers found that the Urolift procedure is a novel, minimally invasive approach to treating benign prostatic hyperplasia that lifts or holds the enlarged prostate tissue out of the way so it no longer blocks the urethra. Recent clinical trials, including prospective, sham controlled, randomized studies, have shown that the Urolift procedure is safe and effective in relieving lower urinary tract symptoms due to benign prostatic hyperplasia without significantly compromising sexual function. Compared with transurethral resection of the prostate and photoselective laser vaporization of the prostate, the Urolift is minimally invasive procedure without a requirement of general anesthesia and with a potentially shorter operative time. Final Result: The reviewers determined that the services at issue were likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Reviewers 1, 2, and 3 are board certified in urology 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

The parent of a 3-year-old male enrollee has requested speech therapy, applied behavioral analysis (ABA) therapy, and occupational therapy for treatment of the enrollees autism spectrum disorder. Findings:  The physician reviewer found that the medical literature strongly supports the treatment of autism with ABA therapy. ABA therapy has been proven to be an effective therapy based on multiple controlled studies (Turner and Stone). This patient has been diagnosed as autistic and ABA therapy remains the documented therapy of choice in this setting; therefore, ABA therapy is medically necessary at the requested frequency. The scientific literature also strongly supports the value of speech therapy in autistic children. Goldsteins paper discusses the multiple techniques that can be successful in teaching autistic children to communicate. A paper by Turner and colleagues is a controlled study comparing autistic children who did and did not receive speech therapy. Those who did receive therapy had far greater communication skills than those who did not receive speech therapy. The report of the American Speech-Language Hearing Association states that all autistic children can benefit from speech therapy. This report emphasizes that age, either early or late in life, is not a barrier to speech therapy. There is also strong scientific evidence supporting occupational therapy in autistic children. Pfeiffer, et al, reported on an extensive meta-analysis of the literature and concluded that occupational therapy is effective in reducing many of the unwanted mannerisms associated with autism. In conclusion, it is medically necessary that this patient receive the requested 10 hours per week of ABA therapy with 20 hours of consultation per year, the requested speech therapy at a frequency of 30 minutes twice a week and the requested occupational therapy. All therapies should be continued for a minimum of six months with re-evaluation at the end of the six-month period.
Appeal type: Medical Necessity
Decision: Upheld

A 61-year-old female enrollee has requested a power wheelchair for treatment of her neuropathy and rheumatoid arthritis. Findings:  The physician reviewer found that the documentation provided for review does not support the medical necessity of the requested power wheelchair. According to the Centers for Medicare and Medical Services (CMS), the determination of medical necessity for a power operated vehicle (POV) requires documentation that the patient is unable to ambulate independently with use of an assistive device, does not have sufficient upper extremity function to propel a manual wheelchair, and has demonstrated the ability and willingness to safely operate a POV. In addition, the POV must be needed in order for the patient to perform mobility related activities of daily living within the home. In the case under review, records indicate that the patient is non-ambulatory but has sufficient upper extremity function to self propel a lightweight manual wheelchair within the home environment. Therefore, the patient does not meet generally accepted criteria for the medical necessity for the requested power wheelchair.
Appeal type: Medical Necessity
Decision: Overturned

A 66-year-old female enrollee has requested for laparoscopic biliopancreatic diversion with duodenal switch (BPD/DS) for treatment of her obesity and degenerative joint disease. Findings:  The physician reviewer found that weight loss is probably slightly greater and the risk of missing a gastric cancer is eliminated with the BPD/DS procedure. While morbidity from both procedures is considerable; it is arguably greater with Roux-en-Y. A particular point is that nutritional differences are common and potentially severe with both operations. Furthermore, the results achieved with gastric banding are not likely to be sufficient in this case.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for advanced lipoprotein testing. Findings:  Three physician reviewers found that the records documented that this patient had increased coronary risk. Guidelines for the management of cardiac risk and dyslipidemia have been established, are periodically updated by expert committees, and are endorsed by several national organizations. These guidelines currently do not recommend routine performance of specialized tests in the context of assessing coronary risk, including lipoprotein-associated phospholipase A2, sub-classifications of low-density lipoprotein (LDL), high-density lipoprotein (HDL) subclasses, lipoprotein (a), C-reactive protein, insulin, fibrinogen, and homocysteine. Treatment change or addition based on the results of screening with these specialized tests has not been shown to improve cardiac outcome incremental to what is achievable by treatment based on standard risk factor profiling and basic lipid analysis. Although results of some of these specialized tests may be abnormal and considered independent risk markers for coronary disease, there is a lack of controlled trials that demonstrate outcome benefits by treating routinely obtained abnormal results. Therefore, advanced lipoprotein testing was not likely to have been superior over other methods of evaluating this patient.Final Result: The reviewers determined that the services at issue were not likely to have been 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 sub-specialty certification in cardiovascular disease 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

Nature of Statutory Criteria/Case Summary: An enrollee has reimbursement for DecisionDX-melanoma gene assay that was performed for evaluation of the enrollees cutaneous melanoma. Findings:  The 3 physician reviewers found that the staging and prognosis of cutaneous melanoma is classically determined. As per this system, this patient would have been staged as pT3aN1 (Stage IIIa). This has an expected ten year survival of about 63%. DecisionDX is a study of 31 genes in melanoma cells. It then classifies that melanoma as either high or low risk for recurrence. The National Comprehensive Cancer Network (NCCN) guidelines state there is interest in these newer genetic profiles, but only in the context of a clinical trial. Currently, medical studies are not clear as to how DecisionDX data compares to the 10 year data by the Balch determinations and whether it is useful in clinical practice for patients with a good prognosis, as is true in this patients case. In sum, DecisionDX-melanoma gene assay that was performed was not likely to have been more effective than the standard options available for the evaluation of this patients medical condition. Final Result: The 3 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: Physician reviewer number one is board certified in internal medicine with sub-specialty certification in medical oncology 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.Physician reviewer number two is board certified in internal medicine with sub-specialty certification in medical oncology 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.Physician reviewer number three is board certified in internal medicine with sub-specialty certification in medical oncology 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 Guanfacine HCL ER 1 mg. The American Association of Pediatrics (AAP) recommends evidence-based parent and/or teacher-administered behavior therapy as the first-line of treatment for preschool aged children with ADHD. The physician reviewer found that the AAP further states that a provider may prescribe methylphenidate if the behavior interventions do not provide significant improvement and there is moderate-to severe continuing disturbance in the childs function. In addition, Guanfacine falls in the non-stimulant medication category, which is not Food and Drug Administration (FDA) approved for use in patients under the age of six years of age. The records provided for review do not document that the patient has tried or failed any methylphenidate formulations, consistent with the recommendations from the AAP. Therefore, the requested Guanfacine HCL ER 1 mg is not medically necessary for treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Overturned

A 36-year-old male enrollee requested authorization and coverage for an allogenic stem cell transplant.  The health plan has denied this request indicating that the requested therapy is considered experimental for treatment of the enrollees cancer.  Three physician reviewers performed an experimental/investigational Independent Medical Review. All three-physician reviewers concluded that the requested therapy is likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy.  The health plan's denial was overturned.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: A 48-year-old female enrollee has requested reimbursement for the laboratory test to monitor infliximab serum levels and test for anti-infliximab antibodies. Findings:  Two physician reviewers found that the laboratory test to monitor infliximab serum levels and test for anti-infliximab antibodies was not likely to have been more beneficial than other available standards of treatment for the patients medical condition. Monitoring patients on infliximab with measurement of infliximab levels and antibodies to infliximab continues to be an area of intense investigation. In general, infliximab levels correlate inversely with disease activity. However, there are no controlled data which have identified the optimal drug level and the issue remains speculative. The algorithmic approach has not been validated prospectively and there appears to be no impact on clinical efficacy compared to empiric dose titration. AGA guidelines indicate that there is a very low quality of evidence to support reactive drug level monitoring. In this case, the patient was diagnosed with small bowel Crohns disease and managed on thiopurine and infliximab. Budesonide was added to the patients medication regimen to maintain disease control. The patient underwent testing for infliximab levels and antibodies to infliximab to determine if her disease was under adequate control. This reactive drug level monitoring, however, has low quality of evidence to support its use, as indicated in AGA guidelines. Therefore, the laboratory test to monitor infliximab serum levels and test for anti-infliximab antibodies provided was not likely to have been more beneficial than other available standards of treatment for the patients medical condition. Final Result: Two of the three physician reviewers found that he requested the laboratory test to monitor infliximab serum levels and test for anti-infliximab antibodies providedas not likely to have been more beneficial than other available standards of treatment for the patients medical condition.  Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in internal medicine with a 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: Experimental/Investigational
Decision: Upheld

A 30-year-old male enrollee requested authorization and coverage of a capsule endoscopy. The Health Plan denied the request indicating that the requested procedure is considered experimental for evaluation of the enrollees apparent Crohns disease.Three physician reviewers performed a medical necessity Independent Medical Review. Two physician reviewers concluded that the requested procedure is not likely to be more beneficial for the treatment of the enrollee's medical condition than any available standard therapy. One physician reviewer concluded that the requested procedure is likely to be more beneficial for the treatment of the enrollee's medical condition than any available standard therapy. Because two of the three physician reviewers concluded that the requested procedure is not likely to be more beneficial for the treatment of the enrollee's medical condition than any available standard therapy, the Health Plans denial has been upheld.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for brachytherapy provided for treatment of the enrollees breast cancer. Findings: All three physician found that the submitted documentation supports the services at issue in this clinical setting.  Accelerated partial breast irradiation (APBI) is considered an acceptable standard treatment for patients with early stage breast cancer meeting stringent criteria. This patient meets ABPI criteria set by the American Society for Radiation Oncology. APBI may be delivered using external beam radiotherapy, brachytherapy, or intraoperative radiation therapy. In this particular patient, the use of IORT also allowed her to finish her breast cancer treatment up to six weeks earlier versus conventional whole breast fractionated photon therapy, and thus begin chemotherapy for her multiple myeloma sooner. In sum, brachytherapy provided was likely to have been more efficacious than other available treatment alternatives. Final Result: All three physician reviewers determined that the services at issue were likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: All three physician reviewers are board certified in radiation oncology and are actively practicing. The reviewer 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:An enrollee has requested authorization and coverage for Mavyret 100/40mg, three times daily, for eight weeks.  Findings:  The physician reviewer found that submitted documentation supports the medical necessity of the requested medication. According to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with limited life expectancy due to nonliver-related conditions. In this case, the submitted medical records support that the patient has a positive diagnosis of hepatitis C and a failure of a prior medication trial, and therapy with Mavyret would be consistent with AASLD and IDSA guidelines at this time. Accordingly, Mavyret 100/40mg, three times daily, for eight weeks, is medically necessary for treatment of the patients medical condition.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 a subspecialty certification in infectious disease, and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 56-year-old male enrollee has requested psychotherapy treatments at a frequency of 1-2 times per week for treatment of his behavioral health issues. Findings:  The physician reviewer found that a review of the literature including the practice guidelines from the American Psychiatric Association (APA) suggest the use of supportive psychotherapy to decrease in frequency as treatment continues. This patient is currently in the maintenance phase of treatment and to be seen twice weekly appears to be more detrimental to this patient in terms of fostering dependency. As such, this patient does not require therapy at the frequency of 1-2 times per week, and should be seen on a less frequent basis of every other week to adequately and safely address his medical condition. For these reasons, the medical necessity of psychotherapy visits has been established at the frequency of twice per month.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a 16-year-old male enrollee has requested residential level of care for treatment of the enrollees behavioral health issues.  Findings:  The physician reviewer found that according to American Psychiatric Association (APA) practice guidelines, this patient did not meet the requirements for residential detoxification services from during the said timeframe. Specifically, the records do not indicate that the patient demonstrated chemical substance withdrawal complications, a major medical complication, or persistence of severe neurological or psychological symptoms. Since none of these factors were present in the records provided for review, the patient could have adequately been treated in a less restrictive environment and the criteria for discharge were met. In addition, the Milliman Care Guidelines for hospital discharge includes lack of harm to self or others and lack of impairment in essential functions. The record available for review does not document any impairment in this area; therefore the services at issue were not medically necessary for treatment of the patients medical condition.