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 three uninterrupted cycles of residential treatment at Psychologist Care and Healing Treatment Center, followed by three months of step down treatment. Findings:  The physician reviewer found that the submitted documentation does not support the medical necessity of residential placement at this time. Although patient needs vary case-by-case, a four-month residential stay is a lengthy admission by community standards. The patient did have an emotional response at the prospect of discharge, but there was no evidence of an underlying acute psychiatric syndrome or the need for access to specialty care in a supervised setting 24-hours per day. The case file did not include records from the residential program demonstrating the need for the requested services, such as a psychiatric evaluation, psychosocial assessment, interpretative summary, physician narrative, multidisciplinary treatment plan, or progress notes. Modern psychiatric practice favors treatment in the community as outcome measures and therapeutic gains are optimized in this environment. The records do not indicate that comprehensive, evidence-based services provided in a less restrictive treatment setting is unsafe, insufficient or inadequate. The current medical evidence does not support the requested services in this clinical setting. Therefore, three uninterrupted cycles of residential treatment at Psychologist Care and Healing Treatment Center, followed by three months of step down treatment are not medically necessary for the 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 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 Epclusa for 12 weeks for treatment of her hepatitis C virus.  Findings: The physician reviewer has found that according to 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 life expectancy less than 12 months due to non-liver-related conditions. This applies to all cases, regardless of fibrosis stage. Per the guidelines, Epclusa for 12 weeks is recommended as a first-line regimen for non-cirrhotic treatment-naive genotype 3 patients. This is based on the ASTRAL-3 trial for Epclusa, which showed a high cure rate of 98% (Foster, et al). AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment (Jezequel, et al). For these reasons, treatment is needed at this time, and the requested treatment with Epclusa for 12 weeks is medically necessary for the treatment of this patients hepatitis C infection. 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 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: Urgent Care
Decision: Upheld

The parent of a three-year-old male enrollee has requested urgent care services for treatment of the enrollee's ashthma.  Findings:  The physician reviewer found that the submitted documentation demonstrates that a prudent layperson would not have sought immediate medical attention on the date in question. Asthma is a chronic condition that manifests episodically and may cause serious medical problems. In this case, the clinical documentation submitted does not demonstrate the patient had exacerbation of asthma with the upper respiratory infection. The patient was not short of breath, his lungs were clear to auscultation, and his vital signs and oxygen saturation were both normal. Moreover, the patient was not 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. In sum, the services provided did not meet prudent layperson criteria for emergency care.
Appeal type: Medical Necessity
Decision: Upheld

A 42-year-old female enrollee has requested gluten-free medication/injections with a certification from the manufacturer for treatment of her Celiac disease. Findings:  The physician reviewer found that the patient is tolerating the allergy shots twice weekly with only local reaction manageable with hydrocortisone cream, and has no systemic reaction. There is no evidence in the peer-reviewed medical literature to support the contention that gluten in allergy shots (if any) has any impact to gluten enteropathy. For these reasons, the request by the patient to have gluten-free allergy shots from a different manufacturer with certification is not medically necessary and therefore should not be approved.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested Nuvigil for treatment of his medical condition. Findings: The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication.  There is no documentation of narcolepsy, idiopathic hypersomnia or shift workers sleep disorder.  There is no documentation of daytime hypersomnia from obstructive sleep apnea despite treatment with optimal CPAP.  There is no indication for Nuvigil.  All told, the requested medication Nuvigil is not medically necessary for the treatment of this patient.  Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in pulmonary 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

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for intensive outpatient program (IOP) services. The Child and Adolescent Level of Care Utilization System (CALOCUS) provides a framework for determining the clinically appropriate level of care for a child or adolescent in mental health treatment.  Although the patient is age 18, the CALOCUS criteria will be used instead of the adult criteria, due to her developmental status as she was under the care of her parents and attending high school when her IOP treatment began, and continued to live at home during the course of her treatment. With regard to risk of harm, the records support a score of 3. The patient has a significant risk of harm, due to recent psychiatric hospitalization for suicidality and self-harm, and continued suicidal thoughts and urges to self-harm during IOP treatment. In terms of functional status, the records support as score of 3. The documentation noted moderate functional impairment, due to interpersonal conflicts and struggles with daily activities including sleeping and eating. With regard to comorbidity, the records support a score of 3. The patient has significant comorbidity, due to recent substance use, and diagnoses of depression and anxiety. In terms of the level of stress of the recovery environment, the records support a score of 2. The patient has a mildly stressful environment due to disruptions caused by the shelter-in-place orders, completion of high school, and pending transition to college. With regard to level of support of the recovery environment, the records support a score of 2 due to the parents participation in treatment. In terms of resiliency and treatment history, the records support a score of 3. The patient has moderate and/or equivocal resiliency and/or response to treatment, due to persistence of symptoms despite an extensive treatment history at various levels of care. With regard to treatment acceptance and engagement, the records support a score of 2. The patient participated in treatment, with some struggles in fully implementing the strategies learned. Thus, the patient has at total score of 18. In this case, the recommended level of care is high-intensity community-based services. This is consistent with the IOP level of care that the patient received. Therefore, IOP services were medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested services 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

The patient is a 10-year-old female with a family history of mitral valve prolapse involving her father and brother. The details of the clinical condition of the patients father and brother are not known. The patient is asymptomatic at this time. A request has been made for a cardiac consultation and echocardiogram. The Health Plan indicates that the requested services are not medically necessary in the absence of symptoms or physical findings.Most cases of mitral valve prolapse are not inherited except in rare circumstances when they are associated with a generalized connective tissue disorder such as Marfans syndrome or Ehlers-Danlos syndrome. In cases involving a generalized connective tissue disorder, mitral valve prolapse is potentially inheritable in an autosomal dominant fashion (50% of offspring). If the patients father and brother do not have features suggestive of a generalized connective tissue disorder then a decision to refer the patient for a cardiac consultation and echocardiogram should be based on the patients symptoms or physical exam findings (e.g., a murmur). However, if a generalized connective tissue disorder is suspected, then providing relatives of afflicted patients with a cardiac consultation and an echocardiogram is reasonable since some findings of generalized connective tissue disorders can be elusive on physical exam (e.g., aortic enlargement).Since no evidence has been provided that the mitral valve prolapse experienced by the patients father and brother is associated with a generalized connective tissue disorder, and the patient is not currently symptomatic, the requested services are not medically necessary at this time. Therefore, the Health Plans denial should be upheld at this time. However, if there is evidence that the patients father or brother has a generalized connective tissue disorder then the requested services should be authorized.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The enrollee has requested authorization and coverage for drug-induced sleep endoscopy for evaluation of his obstructive sleep apnea.  Findings: The physician reviewer has found that the request for a drug-induced sleep endoscopy is not medically necessary for evaluation of the patients medical condition. The medical records submitted for review does not support the requested study. There is no documentation of daytime hypersomnia which is a cornerstone for a diagnosis of sleep apnea or that the patient is obese. There is no diagnostic polysomnogram provided to support a diagnosis of sleep apnea. In addition, there is no Epworth Sleepiness score or documentation of an abnormal Mallampati score noted. Moreover, there is no evidence of any primary sleep disorder or documentation that the patient is at a high risk for sleep apnea. For the reasons provided, the requested services are not medically necessary for evaluation of the patients medical condition. Final Result: The reviewer determined that the requested services are not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in pulmonary 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for methadone three times per day and Norco for treatment of the enrollees chronic pain due to fibromyalgia and cervical and lumbar radiculopathy. Findings: The physician reviewer has found based on the presented clinical records, the request for methadone and Norco are medically necessary for treatment of the patients medical condition. In this case, the patient presents with chronic nonmalignant pain. Her diagnoses include fibromyalgia and cervical and lumbar radiculopathy. Treatment with opioid medication can be considered as part of the standard of care when treating patients with chronic nonmalignant pain. There is evidence of failed treatments including non-medication management, interventional care, and non-opioid medications. Methadone, a long-acting medication is being prescribed for baseline pain and Norco which is a short-acting combination opioid is being used for intermittent or breakthrough pain. In terms of the dosing, the daily MED being requested is 120 mg per day. Guidelines have identified a threshold ranging from 50 mg to 200 mg per day in terms of the threshold at which increased vigilance should be exercised. In this case, the patients medications are providing a significant improvement in pain and allowing her to continue working based on her assessment in March 2017. Also, there is no evidence of abuse or addiction with consistent urine drug screening and the patient has been managed with these medications on a long-term basis. The patient reports worsening pain and difficulty functioning when her medications were tapered which supports the medical necessity of ongoing use. Another trial of opioid medication tapering should be considered in approximately six months as guidelines support an attempt to taper every six months to assess whether ongoing chronic opioid therapy is medically necessary. For these reasons, the request for methadone 5 mg three times per day TID and Norco 10/325 mg are medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the requested medications 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 physical medicine and rehabilitation with sub-specialty certification in pain 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: Experimental/Investigational
Decision: Overturned

A 64-year-old male enrollee has requested Erbitux or Vectibix, in combination with irinotecan for treatment of his colon cancer.  Findings:  Two physician reviewers found that in this patients case, the requested medications are likely to be more effective than other available alternatives.  This patient has metastatic colorectal cancer that has progressed on the combination of Xeloda and Avastin.  At this time, changing his treatment to a regimen of single agent irinotecan in combination with an EGFR-inhibitor, either Vectibix or Erbitux is medically appropriate.  Erbitux or Vectibix is not recommended when the patient has progressed on either of these agents in the past.  In this case, the patient was briefly treated with Erbitux, but progression of disease while on this agent was not documented.  Therefore, use of Erbitux at this time would be considered a continuation of treatment and not re-treatment.  In sum, Erbitux or Vectibix, in combination with irinotecan is likely to be of greater benefit than other treatment options.
Appeal type: Experimental/Investigational
Decision: Upheld

A 38-year-old female enrollee has requested AmniSure Rupture of Membranes test for evaluation of her  reported leaking fluid during pregnancy.  Findings:  Two physician reviewers found that the diagnosis of rupture of membranes is made based on patient history and clinical examination, including a speculum evaluation of the vagina and cervix.  Typically, the patients history, with its description of leakage of fluid, can be of help to rule in or rule out the diagnosis.  This is coupled with a sterile speculum examination to evaluate vaginal/cervical secretions, evaluation of the pH of any secretions, and a microscopic examination for cervical ferning.  In this patients case, there was no documentation of a sterile speculum/pelvic examination.  There is no documentation of an evaluation of any vaginal secretions by pH or microscopic examination.  In sum, the AmniSure Rupture of Membranes test performed was not likely to have been more effective than other methods of evaluating this patient for possible rupture of membranes.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested breast tomosynthesis for evaluation of her medical condition. Findings: Three physician reviewers found that tomosynthesis is a technique that was developed as a problem solving adjunct to routine mammography. Applying the same basic concept as computed tomography (CT) scanning, the logic is that by separating the various layers of breast tissue, one can better detect abnormalities. This has been shown to be most useful in the evaluation of the dense breast. It is specifically those patients who have dense breasts that can benefit most from tomosynthesis. The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor. For the reasons provided, breast tomosynthesis was likely to be more beneficial than other modalities.  Final Result: The reviewers determined that the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications:  All three reviewers are board certified in diagnostic radiology and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 23-year-old female enrollee requested authorization and coverage of the medication Depo-Provera. The Health Plan  denied the request indicating that the requested medication is not medically necessary for purposes of the enrollees contraception.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested medication is not medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld

A 29-year-old male enrollee requested authorization and coverage of gastric bypass surgery with duodenal switch. The Health Plan denied the request indicating that the requested procedure is considered experimental for treatment of the enrollees medical condition.Three physician reviewers performed an experimental/investigational Independent Medical Review. Two physician reviewers concluded that the requested procedure is not likely to be more beneficial for 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 treatment of the enrollee's medical condition than any available standard therapy. Because two of the three  physician reviewers concluded that the requested surgery is not likely to be more beneficial for 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 the Afirma Gene Expression Classifier for evaluation of her thyroid nodule. Findings:  Three physician reviewers found that there is sufficient peer-reviewed scientific literature demonstrating the benefits of genetic testing in thyroid nodules. The American Thyroid Associations guidelines state that for nodules with AUS cytology, after consideration of worrisome clinical and sonographic features, investigations such as repeat [fine needle aspiration] FNA or molecular testing may be used to supplement malignancy risk assessment in lieu of proceeding directly with a strategy of either surveillance or diagnostic surgery. In this case, the cytopathology of the thyroid nodule was consistent with AUS. The result of the Afirma was suspicious for malignancy. This information was important to determine the extent of surgery, such as a hemi-thyroidectomy versus total thyroidectomy. Without the results, a hemi-thyroidectomy would likely have been performed, but a thyroidectomy would be indicated if malignancy was found. Final Result: The reviewers determined that the testing 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: Reviewers 1, 2, and 3 are board certified in internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism 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.