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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for individual therapy every two weeks for treatment of the enrollees behavioral health conditions. Findings:  The physician reviewer found that The physician reviewer found the submitted documentation supports the medical necessity of the requested services. The literature indicates that psychotherapy for bipolar disorder is effective for symptom management. The literature does not specify the exact frequency of psychotherapy. Typically, the frequency is dictated by the symptom presentation of the patient. In this case, the patient has mood symptoms that have continued over the past several months.  The progress notes indicate tearfulness and episodes of increased depression and anxiety.  She has been participating in therapy, but her symptoms are not significantly improving as evidenced by her PHQ-9 scores and clinical symptoms. The medical evidence supports the requested services in this clinical setting. Therefore, the requested individual therapy every two weeks is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in 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

The parent of a 16-year-old male enrollee has requested for cognitive behavioral therapy for treatment of the enrollees obsessive compulsive disorder.  Findings:  The physician reviewer found that an IOP level of care is consistent with the Child and Adolescent Level of Care Utilization System (CALOCUS) to ensure the patient receives the intensity of therapy necessary in order for him to make progress.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for physical therapy twice per week. Findings:  The physician reviewer found that the request for authorization and coverage for physical therapy twice per week is not medically necessary for treatment of this patients symptoms. The documentation indicates that the patient has been evaluated by physical medicine and rehabilitation, pain management, and gynecology specialists. The impression is that the patients condition is low back/sacroiliac related. However, the records report that prior physical therapy has not led to functional improvement. The provider noted that the patient was also treated with prior therapy for pelvic floor dysfunction without improvement. Although a review of the literature reports some beneficial effects for pelvic floor myofascial dysfunction from physical therapy, this patients records do not support the need for pelvic floor therapy. All told, the request for physical therapy twice per week is not medically necessary for treatment of this patients medical condition. 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 physician 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: Overturned

The parent of a four-year-old female has requested a standing frame for the treatment of the enrollees epilepsy with severe developmental delay. Findings:  The physician reviewer found that the submitted clinical evidence demonstrates that the patient is unable to use a folding wheeled walker. The requested standing frame is medically reasonable to assist in improving her standing endurance, reduce contracture and improve bone density. The use of a standing frame by this patient is clinically appropriate and indicated.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential treatment services for treatment of the enrollees behavioral health conditions. Findings:  The physician reviewer found that in this case, the patients alcohol use disorder was complicated by co-occurring mood and anxiety disorders.  This is of particular relevance since it has been well-established in both clinical practice and the medical literature that anxiety-ridden mood disorders, without the complication of addictive illness, are difficult to treat and in general have poorer outcomes.  Notwithstanding, the patients alcohol use was central to her daily routine and contributed to her significant impairment across multiple domains of functionality.  The patient was not able to stay sober with Alcoholics Anonymous.  The patient had failed a course of psychiatric treatment in the outpatient setting.  The patient lived alone while the patient's residence approached inhabitability due to hoarding.  The patient had limited social supports.  The patient's past history of poor adherence suggested insufficient motivation.  In this clinical setting, the services and setting were safe, appropriate and consistent with good practice, while the duration of treatment aligned with community standards.  Additionally, the services provided during the disputed timeframe were for active treatment, and reasonably expected to improve her condition and prevent a more serious episode of illness. Final Result: The reviewer determined that the services at issue were medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: The reviewer is board certified in psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested positron emission tomography (PET) scan for evaluation of her medical condition. Findings: The physician reviewer found that there is sufficient support for the requested services in this patients case.  This patient has been incompletely staged.  It is not known whether she has metastatic disease beyond the axilla or not.  Her breast tumor was enlarging, and so chemotherapy was started urgently before scans could be done. In this clinical setting, the PET scan is medically necessary and appropriate at this juncture in her care.  There is sufficient medical evidence supporting its use during neoadjuvant chemotherapy to evaluate responses. Multiple lines of evidence and standard care dictate that the requested PET scan 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 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

A 57-year-old female enrollee requested authorization and coverage of the medication Provigil. The Health Plan denied the request indicating that the requested medication is not medically necessary for treatment of the enrollees daytime sleepiness.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: Medical Necessity
Decision: Upheld

A 63-year-old male enrollee has requested monthly electrical stimulation and chiropractic adjustment for the treatment of the enrollees back pain. Findings:  The physician reviewer found that the submitted documentation does not specifically indicate the daily lifestyle and function of the patient. The office notes lack information related to an outcome assessment of the patient. The provider noted that the patient has instability of the lumbar spine and has been given therapeutic exercises and instruction for use of heat or ice when exacerbations occur. Per the provider, treatments have been effective in reducing his symptoms and have allowed him to continue to perform physical activities. The submitted documentation does not indicate the location of pain, quality of pain, level of function and whether the condition is better, worse or the same. Additionally, there is no documentation as to the severity of the pain. There is a lack of documentation as to the resolved issues from the previous office visit or new complications which may have arisen and the cause of these conditions. The submitted records do not include any completed orthopedic, neurological or muscular analysis. There is no documentation of any short-term or long-term goals and expected functional outcomes. The providers notes do not indicate treatment effectiveness from visit to visit or document functional gains. The submitted documentation does not describe the exercises that were given, and there is a lack of support justifying lumbar instability. Based on the records provided, clinical indications for monthly electrical stimulation and chiropractic adjustment have not been established.
Appeal type: Medical Necessity
Decision: Upheld

A 55-year-old male enrollee requested reimbursement for the medication Sporanox. The Health Plan denied the request indicating that the medication at issue was not medically necessary for the treatment of the enrollees fungal infection.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the medication at issue was not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 19-year-old female with a history of major depression currently relatively stabilized on Paxil 40 mg per day but with the continued side-effect of fatigue. The patients fatigue has been successfully treated with Provigil. A number of prior medication trials including Effexor, Paxil CR, and Trazadone were not effective for her depression. While receiving treatment without Provigil the patient encountered academic difficulties; the addition of Provigil led to academic improvement. Based upon these results the patients provider has recommended continued treatment with Provigil. In addition, the provider notes Provigil does not have dependency issues found with other stimulants.There is literature supporting the use of Provigil both as an antidepressant adjunct and for treatment of residual fatigue. The patient underwent a number of medication trials prior to having success with Paxil. Furthermore, the residual fatigue she experiences has been effectively treated with Provigil. Given this success, changing the patients medication from Paxil to another antidepressant in the hopes of avoiding residual fatigue is not medically indicated. Also, because her residual fatigue has been successfully treated with Provigil, discontinuing treatment with Provigil is not medically indicated.Based upon the information set forth above, I have determined the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

A 29-year-old male enrollee has requested bariatric surgery (gastric bypass) for the treatment of his morbid obesity. Findings:  The physician reviewer found that this patient clearly meets the criteria set forth by the National Institutes of Health for surgical treatment of obesity. With a BMI of 49, weight loss surgery is medically indicated and necessary for this patient, as it is not likely that he will be able to lose weight and maintain the weight loss through non-surgical means. There is no scientific evidence demonstrating that structured diet or exercise plans have been successful in the treatment of the morbidly obese. In fact, the Swedish obesity study identifies that even though there may be reduction or resolution of some symptoms with diet and exercise, surgery has the longest and best long-term outcome for the obese.
Appeal type: Medical Necessity
Decision: Upheld

A 55-year-old female enrollee has requested Testim 1% (50mg) gel for treatment of her menopause.  Findings:  The physician reviewer found that the records do not provide evidence that Testim is medically necessary for treatment of this patients medical condition. The records lack laboratory data confirming low testosterone levels and other medical documentation of consequences of testosterone deficiency, such as bone loss, that could benefit from replacement. In addition, there are few data regarding the safety and efficacy of testosterone therapy in women who are not using concomitant estrogen therapy or for the use of testosterone therapy for longer than six months. According to the North American Menopause Society (NAMS), clinically available laboratory assays do not accurately detect testosterone concentrations at the values typically found in women, and no testosterone level has been clearly linked to a clinical syndrome of hypoandrogenism or testosterone insufficiency. Basaria and Dobs reported that early results from small studies show that transdermal testosterone therapy results in moderate improvement in libido in surgically menopausal women on estrogen. However, the published data are of short duration and are limited to only 24 weeks. Based on the information provided for review, the requested Testim 1% gel is not supported as medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 19-year-old male with idiopathic short stature and constitutionally delayed puberty. He was born the smaller of two twins weighing 2 pounds with his sibling weighing 5 pounds 4 ounces. The mid-parental height approximates 68 inches. On October 2005 the patients bone age was 15.5 years, while his height was near 53. His adult height prediction on these bases should approximate 54. He has had an endocrine workup, which revealed normal GH responses to stimuli, normal adult male hormone levels and a normal IGF-1 level of 184 in October 2004. Based upon the information provided, it appears the patient has been on growth hormone therapy since January 2006. At issue is whether growth hormone therapy is medically necessary for treatment of the patients medical condition.Review of the submitted clinical evidence demonstrates the patient meets medical necessity criteria for growth hormone therapy. In accordance with the AACE Medical Guidelines for growth hormone therapy, the therapy is medically necessary for patients such as this patient who was a small for gestational age infant who has not caught up, and is falling further from normal percentiles, and/or has idiopathic short stature and is not projected to achieve an adult height in the normal range and is under the care of a pediatric endocrinologist. The problem is however that the patients remaining growing time is very short and it is not known to what extent such therapy will be beneficial. Therefore, growth intervals should be obtained on a regular basis (every three months) to document that the patient is continuing to grow. In addition, a knee x-ray would be helpful to show the state of the epiphyses in the knee. Based upon the information set forth above, I have determined the requested therapy is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for the magnetic resonance imaging (MRI) guided high intensity focused ultrasound ablation for treatment of the enrollees adenomyosis. Findings:  The physician reviewer found that MRI guided high intensity focused ultrasound ablation has been U.S. Food and Drug Administration (FDA) approved for treatment of fibroids, not adenomyosis. There is limited data on the use of magnetic resonance imaging (MRI) guided high intensity focused ultrasound ablation for patients with adenomyosis. In addition, Stewart and colleagues reported that studies are needed to determine long-term outcome and optimal candidates for this procedure; comparative studies are also needed. Further, the authors noted that the only guaranteed treatment for adenomyosis is total hysterectomy. This patient has requested MRI guided high intensity focused ultrasound ablation as treatment for her painful and heavy periods with a diagnosis of adenomyosis. This patient has not exhausted standard therapies for her condition. All told, the requested MRI guided high intensity focused ultrasound ablation is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: All three reviewers determined that the requested procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewer number one is board certified in obstetrics and gynecology 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 obstetrics and gynecology 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 obstetrics and gynecology 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 Zioptan eye drops for treatment of his elevated intraocular pressure associated with open angle glaucoma.  Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested medication.  Various intraocular pressure lowering eye drops, such as timolol, have ocular surface toxicity leading to symptoms such as redness and irritation.  Zioptan causes less ocular surface toxicity than other prostaglandin analog medications, such as Lumigan.  Chabi and colleagues demonstrated in a randomized double-masked clinical trial that the intraocular pressure lowering effect of preservative-free tafluprost (Zioptan) was non-inferior to preservative-free timolol.  Based on the current medical evidence, the patient is less likely to suffer redness and irritation due to ocular surface toxicity and is likely to achieve good intraocular pressure reduction with the use of Zioptan eye drops.  All told, Zioptan eye drops are medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

A 63-year-old male enrollee has requested coverage for Synvisc One injections for treatment of the enrollees right knee osteoarthritis. Findings:  The physician reviewer found that upon review of the relevant scientific evidence, the medical necessity of an additional series of hyaluronan injections is not established for this patient. The above cited literature does not support a positive effect from hyaluronan in osteoarthritis of the knee. While there is an advantage to delaying joint replacement as long as possible, the use of repeated hyaluronan injections is not without risk with possible allergic reaction or infection as complications. Moreover, there is no evidence that one brand of hyaluronan injections is more effective than another. At this time, the use of hyaluronan injections in individuals with osteoarthritis of the knee is poorly supported by double-blinded studies and also has a low but present risk of complications. The possibility that the hyaluronic acid molecule will disrupt the effect of inflammatory cytokines affecting osteoblastic and osteoclastic and chondrolytic changes within the knee joint is unlikely. As such, the process of chronic inflammation is not likely to be altered by the hyaluronic acid macromolecule. Further, in the article authored by Colen  et al. which reviewed the use of hyaluronic acid in joints other than the knee joint, it was concluded that there is no strong evidence that hyaluronic acid is superior to other treatments of osteoarthritis such as corticosteroids, physiotherapy or other conservative measures. All told, there is insufficient evidence that an additional course of Synvisc One injections is medically necessary for treatment of the patients knee osteoarthritis.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for speech therapy for treatment of the enrollees speech delay. Findings:  The physician reviewer found that childhood apraxia of speech is difficult to evaluate. In this case, the patient only utilizes four to five words, which indicates a more significant delay than shown on testing. Speech therapy is clinically indicated for this patient particularly to work on speech sounds and words. 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 pediatrics with sub-specialty certification in developmental and behavioral pediatrics 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.