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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential treatment. Findings:  The physician reviewer found that The submitted records support the medical necessity of the services at issue.  In this case, the patients alcohol use was central to her daily routine and contributed to her significant impairment across multiple domains of functionality.  Her drinking was causing problems at work and compromising her judgment.  The enrollee had sleep problems and had misused Ambien for several years.  The enrollee also had co-occurring inattention, anxiety, depression and co-dependent personality traits that fueled recurrent maladaptive relationships. The providers that managed the detoxification recommended residential treatment based on the clinical presentation.  Per the records, the enrollee had not consolidated the treatment gains necessary to succeed in the outpatient setting and was likely to have promptly relapsed in a community-based setting.  The patient had poor concentration and anhedonia.  The enrollee  was anxious and pressured.  According to the records provided, the patient was actively engaged in treatment during the entire admission.  The services and setting were safe, appropriate and consistent with good practice, while the duration of treatment aligned with community standards and facilitated transition to a less restrictive setting.  Additionally, the services provided at the time were reasonably expected to improve her condition and prevent a more serious episode of illness.  In sum, residential treatment were medically necessary for the treatment of this patient.Final Result: The reviewers 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: Physician reviewer number two 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 19-month-old male enrollee has requested speech therapy for treatment of his autism. Findings:  The physician reviewer found that laryngeal/oropharyngeal anatomical abnormalities are not necessary for abnormal language development or abnormal motor behaviors that are seen in children with autistic spectrum disorders. At issue is the notion that plasticity in the developing brain, albeit a brain with underlying neurologic disease, still exists, and can be utilized to improve overall neurologic health. Thus, specific treatment, including speech therapy, can be used to help induce brain plasticity, with the ultimate goal of retraining neural circuitry not compromised by the underlying pathogenetic processes that give rise to expressive and receptive speech delay.
Appeal type: Medical Necessity
Decision: Overturned

The enrollee has requested reimbursement for inpatient psychiatric treatment services provided and prospective authorization and coverage for inpatient psychiatric treatment services. Based on the documentation provided for review, this patient demonstrates multiple risk factors for suicide after discharge from the hospital and is at continued risk of danger to self. Specifically, these risk factors include diagnoses of mood disorder and borderline personality disorder coupled with a history of multiple suicide attempts and non-suicidal self-injury. In addition, the patient has engaged in self-harm and made one suicide attempt while in the hospital and continues to require intermittent one-to-one observation for safety. Moreover, the patient has required inpatient treatment more than once over the past year despite treatment at the IOP and PHP levels of care. According to the American Psychiatric Association (APA) guidelines, this patient is at an elevated risk for suicide compared to the general population given the history of gender dysphoria and presence of a mood disorder. Thus, the inpatient psychiatric treatment services provided and prospective inpatient psychiatric treatment services were and are supported as medically necessary for treatment of this patients behavioral health issues.Final Result: The reviewer determined that the services at issue were and 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 patient has requested authorization and coverage for weekly individual behavioral health therapy sessions. This patient presents with depressive symptoms including mood disturbances, difficulty performing ADLs, and intermittent suicidal ideation. The continued stress of dealing with her gender transition has increased her mood, gender dysphoria and possible psychotic and dissociative symptoms. The American Psychiatric Association (APA) supports individual psychotherapy for major depressive disorder alone or in combination with psychiatric medication management. Researchers found that individual psychotherapy is an evidence-based treatment for patients with major depressive disorder. The authors stated that the current medical literature includes adequate evidence for weekly individual psychotherapy in this clinical setting. This patients records document the presence of depression and gender dysphoria. All told, the requested weekly individual behavioral health therapy sessions are medically necessary for 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 with expertise in psychosomatic 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 51-year-old female enrollee has requested positron emission tomography (PET) scan for evaluation of her metastatic pancreatic carcinoma.  Findings:  Two physician reviewers found that this patient has diffuse pancreatic cancer with metastatic disease to the abdomen and pelvis including the peritoneum. In this clinical setting, conventional CT is difficult to interpret due to the difficulty in separating scar, residual and inactive tumor versus progressive disease. The anatomic size and appearance on conventional imaging is not always sensitive to tumor recurrence. By contrast, the physiologic qualities depicted on PET are valuable in this scenario since the provider has the ability to analyze the intensity of activity within the abdomen and pelvis to determine whether tumor has recurred. Such detection allows for a change in therapy at the earliest time. Therefore, the diagnostic procedure at issue was more beneficial to the patient than any other test.
Appeal type: Experimental/Investigational
Decision: Upheld

The spouse of a 62-year-old male enrollee has requested for a PET scan of the brain for evaluation of the enrollees dementia. Findings:  Three physician reviewers found that PET scans of the brain are typically indicated for localization of seizure foci.  No such foci are suggested in this patient, nor does he have a seizure history.  PET imaging of the brain can also be indicated in cases where a cerebral malignancy is suspected.  There is no suspicion of such a malignancy reported in the record.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for gallbladder surgery with gallstone removal. The Health Plan has denied this request indicating that the requested procedure is not medically necessary for treatment of the enrollees gallstones.At issue in this case is whether the requested gallbladder surgery with gallstone removal is medically necessary for treatment of the patients medical condition.Per a study, gallstones grow inside the gallbladder or biliary tract. These stones can be asymptomatic or symptomatic; only gallstones with symptoms or complications are defined as gallstone disease. Diagnosis is mainly based on clinical symptoms, abdominal ultrasonography and liver biochemistry tests. Symptoms often precede the onset of the three common and potentially life-threatening complications of gallstones (acute cholecystitis, acute cholangitis and biliary pancreatitis). Researchers indicate that gallstones are common in certain areas, affecting an estimated one in seven adults. Fortunately, they are asymptomatic in up to 80 percent of cases, and current guidelines do not recommend cholecystectomy unless they cause symptoms. The patient has had chronic right upper quadrant and abdominal pain for over one year. The patient has had other symptoms occasionally including nausea, vomiting and diarrhea. Work up has generally otherwise been negative, with positive findings of cholelithiasis, polyp and sludge on gallbladder ultrasound with transient elevation of liver function tests previously. Gastric emptying study is normal. Magnetic resonance imaging shows cholelithiasis without other masses or causes of abdominal pain. The patient likely has chronic cholecystitis and there is no other finding in the area to support other etiology of pain. Gallbladder surgery with gallstone removal is indicated for symptomatic cholelithiasis and right upper quadrant pain without any other clear etiology after thorough work up. Therefore, the gallbladder surgery with removal of gallstones is medically necessary. Final Result: The reviewer determined that the requested procedure 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 general 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:   An enrollee has requested genetic testing (CPT codes 81211, 81201, 81292, 81295) for evaluation of her gastric cancer. Two physician reviewers found that in 2010, the International Gastric Cancer Linkage Consortium (IGCLC) broadened the consensus guidelines for E-cadherin (CDH1) mutation testing to include two gastric cancer cases in family, one confirmed diffuse gastric cancer under age 50, three confirmed diffuse gastric cancer cases in first or second degree relatives independent of age, diffuse gastric cancer in an individual under the age of 40, and a personal or family history of diffuse gastric cancer and lobular breast cancer, one diagnosed under the age of 50. The IGCLC also supports the inclusion of cases where expert pathologists detect in situ signet ring cells and/or pagetoid spread of signet ring cells adjacent to diffuse type gastric cancer. Thus, this patient meets criteria for Lynch syndrome testing as there are two confirmed gastric cancer cases under age 50. Thus, the Lynch syndrome testing (CPT code 81292 and 81295) was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: Two reviewers determined that a portion of 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 partially overturned.  Credentials/Qualifications:  One reviewer is board certified in oncology and hematology and is actively practicing.  Two reviewers are board certified in internal medicine with sub-specialty certification in medical oncology and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The patient has requested reimbursement and prospective authorization and coverage for residential treatment center (RTC) services. Per the American Society of Addiction Medicine (ASAM) criteria, this patient meets Level 3.5 criteria for clinically managed high-intensity residential services. ASAM criteria focuses on six dimensions to determine the appropriate level of care, which includes: (1) intoxication and withdrawal potential; (2) biomedical conditions; (3) emotional, behavioral and cognitive conditions; (4) readiness to change; (5) relapse, continued use, or continued problem potential; and (6) recovery environment. For dimension 1, the patient has mild to moderate withdrawal symptoms per Clinical Institute Withdrawal Assessment (CIWA) scoring. The patient does not have any reported biomedical conditions to meet the requirements for dimension 2. However, the patient meets the criterion for dimension 3, given the presence of post-traumatic stress disorder (PTSD) and major depressive disorder (MDD), which complicate his substance use presentation and treatment. For dimension 4, the patient is willing to change, but not yet ready or able as evidenced by continued avoidance of skills that would promote independence and sobriety. For dimension 5, the patient has been self-medicating his trauma symptoms with substances. The patients symptoms will persist without new adaptive skills firmly in place. The patient does not have significant family support and he lacks a supportive structured environment at home, as required by dimension 6. The patient requires a safe and stable living environment in order to develop his recovery skills. He qualifies for ASAM Level III treatment similar to what patient has received at the current RTC facility. Given the severity of the patients illness, RTC services were and are medically necessary for treatment of this patient. Final Result: The reviewer determined that the services at issue were and 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 expertise in addiction 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

A 45-year-old female enrollee has requested infertility treatments for the treatment of her infertility. Findings:  The physician reviewer found that the American College of Obstetrics and Gynecology (ACOG) guidelines note that infertility is established when a couple has unprotected intercourse for 12 months without conception. They note that evaluation of infertility should be undertaken at this time, unless medical history and physical findings dictate earlier evaluation and treatment.  Additionally, women older than 35 years of age should receive expedited evaluation and treatment after six months of attempted conception, or earlier if indicated.  The ACOG Committee Opinion on Age-Related Fertility Decline concurs, noting that age alone has an impact on fertility. In this case, the patient has apparently attempted conception for at least six months. Her fertility is markedly decreased because of her age, and it would be appropriate and medically indicated to proceed with a basic infertility evaluation, including hormone levels, evaluation of ovarian reserve and semen analysis, with consideration for intrauterine insemination and possible ovulation induction.  Under her circumstances, and based on her age, the more rigorous standard of one year of intercourse prior to infertility evaluation should not be applied in this case.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested proton beam therapy for treatment of his prostate cancer.  The physician reviewer found that review of the submitted documentation fails to establish the medical necessity of the requested services. Proton beam therapy for treatment of prostate cancer is not routinely offered to patients. Other treatment approaches such as intensity modulated radiation therapy (IMRT) are highly effective and well tolerated. Whether proton therapy affords a benefit over other standard approaches such as IMRT for the treatment of prostate cancer remains an area of investigation. To date, there is a lack of compelling data to suggest that proton therapy is superior to or more beneficial than IMRT. There is also the possibility that proton therapy is disadvantageous. The study by Sheets and colleagues concluded that proton therapy has resulted in a greater risk of gastrointestinal toxicity versus IMRT. For the reasons provided above, the requested services are not medically necessary for treatment of the 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 reviewer is board certified in radiation 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: Overturned

A 62-year-old male has requested approval for the brand name medication Lipitor, as opposed to the generic atorvastatin for treatment of his hyperlipidemia.   Findings:  The physician reviewer found that based on review of the available records, this patient presents with hyperlipidemia and diabetes. He was treated with HMG-CoA reductase inhibitor medication (brand name Lipitor). In this circumstance, established guidelines from the Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults support the medical necessity and appropriateness for prescribing HMG-CoA reductase inhibitors in this clinical setting. Generic alternatives to brand name Lipitor have been demonstrated to be of equal effectiveness in treatment of hyperlipidemia through rigorous studies prior to FDA approval. In addition, generic alternatives contain the same active ingredients as their brand name counterparts and are within an acceptable bioequivalent range to the brand name counterpart with respect to pharmacokinetic and pharmacodynamic properties (Davit, et al). However, the inactive ingredients may differ and there may be idiosyncratic reactions in an individual patient. Since this patient has documented intolerable side effects that are temporally associated with the switch from brand name Lipitor to generic atorvastatin, it is medically reasonable to switch his medication from generic atorvastatin to another HMG-CoA reductase inhibitor that is tolerated. As the patient has previously tolerated the brand name Lipitor, its use in this patients care is supported for treatment of his medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 44-year-old female enrollee requested authorization and coverage of myopulse electrotherapy. The Health Plan denied the request indicating that the requested therapy is considered experimental for the treatment of the enrollees abdominal pain.Three physician reviewers performed an experimental/investigational Independent Medical Review. All three physician reviewers concluded that the requested therapy is not likely to be more beneficial for the treatment of the enrollee's medical condition than any available standard therapy. Because all 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: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for computed tomography (CT) of the heart with calcium scoring. Findings:  The physician reviewer found that American Heart Association (AHA) and American College of Cardiology (ACC) have established guidelines for the management of blood cholesterol including evaluation with use of CT of the heart with calcium scoring .The AHA/ACC guidelines note that, Multiple studies indicate the utility of coronary artery calcium measurement in identifying the absence of atherosclerotic pathophysiology in older adults. Per the AHA/ACC guidelines, patients with a low 10-year arteriosclerotic cardiovascular disease risk, defined as 5% or less, should be managed with lifestyle modification. This patient presented with a 10-year arteriosclerotic cardiovascular disease risk of less than 5%. The patients family history is significant for early cardiovascular disease in his father. The patients records do not document any personal history of clinical arteriosclerotic cardiovascular disease, hypertension, or diabetes mellitus. The patient is a non-smoker and is not treated with a statin medication. Overall, a CT of the heart with calcium scoring is recommended when a patients risk is borderline or intermediate. This patient was found to have a low 10-year arteriosclerotic cardiovascular disease risk. For these reasons, the CT of the heart with calcium scoring was not medically necessary for evaluation of this patient. Final Result: The reviewer determined that the services at issue were 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 expertise in cardiovascular 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 65-year-old female enrollee has requested for Gleevec 100mg for treatment of her metastatic melanoma with L576P KIT mutation. Findings:  The physician reviewer found that metastatic melanoma is not sensitive to chemotherapy, and there is no current standard regimen.  Since KIT mutations have been described in 15-20% of melanoma cases, it is medically appropriate to target this receptor in these tumors.  KIT can be inhibited by the drug imatinib (Gleevec), which is more commonly known as an inhibitor of the ABL kinase that is deregulated in chronic myelogenous leukemia.  Gleevec is also approved for use in gastrointestinal stromal cell tumor which harbors KIT mutations.  Although Gleevec would be considered off-label in this clinical setting, there is strong medical evidence that supports its use.  There are phase II trials which show that KIT inhibition can induce durable responses in patients with mutations.  All told, Gleevec 100mg is medically indicated for the treatment of this patient.