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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for parathyroid planar imaging scan (CPT 78070). The parathyroid glands are small endocrine glands in the neck that produce parathyroid hormone in order to regulate blood calcium levels. Hyperparathyroidism is overactivity of the parathyroid glands that can result in excess production of parathyroid hormone and lead to numerous complications. Whereas preoperative sestamibi-technetium 99m scintigraphy was previously an important prerequisite for successful targeted parathyroidectomy, single-photon emission computed tomography/computed tomography (SPECT) and concurrently acquired computed tomography (CT) fusion provides a three-dimensional functional image with advanced contrast resolution to greatly improve preoperative localization of parathyroid tumors. This patient presents with elevated serum calcium, hyperthyroidism, hypercholesterolemia, hypercalcemia, and elevated lipids. Her provider has recommended SPECT with CT fusion, or parathyroid planar imaging scan, to rule-out hyperparathyroidism. This patients symptoms, laboratory results, and clinical history support an indication for parathyroid planar imaging per current medical literature. For these reasons, the requested parathyroid planar imaging scan (CPT 78070) is medically necessary for 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 subspecialty certification in diabetes, endocrinology, and metabolism and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the gene mutation testing (methylenetetrahydrofolate reductase (MTHFR)). MTHFR gene is a B vitamin gene involved in the folate/homocysteine metabolism pathway. Genetic variations in the MTHFR gene have been associated with a number of psychiatric conditions such as depression, schizophrenia, autism, bipolar disorder and dementia. However, there have been conflicting reports on its clinical utility (Wu, et al; Roberts, et al). Mitchell and colleagues reported that, diverse clinical studies have revealed weak and in some cases inconsistent associations of cognition, mood, and neurodevelopment disorders to genes involved in B vitamin metabolism. Based on current medical literature, the gene mutation testing (MTHFR) was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.  Findings:  Three physician reviewers found the gene mutation testing (MTHFR) was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.  Final Result: The reviewers determined that the gene mutation testing (MTHFR) was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.  Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in psychiatry 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

Findings:  The physician reviewer found that an enrollee has requested authorization and coverage for Humira 40 mg/0.8 mL every seven days. This patient has had uncontrolled disease on dosing every 14 days. Researchers found that in the ULTRA 2 trial, it was part of the protocol to change patients to weekly Humira if response was not adequate on Humira every two weeks. In the ULTRA 3 trial, weekly Humira was started for inadequate response or for flare. Current guidelines recommend that when anti-tumor necrosis factor level is low, and anti-drug antibody is low or absent, the drug dose should be increased. Maintaining a dose of 40 mg every other week or changing to a different medication may result in disease flare, disease complications such as dysplasia leading to colon cancer, need for surgery, and hospitalization. For these reasons, Humira 40 mg/0.8 mL every seven days is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medication regimen 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: Medical Necessity
Decision: Upheld

The patient is a 45-year-old woman with a history of severe migraines who has been treated with low dose Botox for four years. She and her physician indicate it is helping, but there is no documentation of change in the headache frequency, severity, or use of acute medication. The clinical notes do suggest the patient has been using increasing amounts of Imitrex and has been suffering worsening headaches. At issue is whether Botox is medically necessary for treatment of the patients condition.Botox is not medically necessary for this patient based on the information provided. The submitted records do not demonstrate a substantial improvement in the patients headaches with the use of Botox. Furthermore, the records do not document the failure of multiple standard preventive medications. The records do suggest the patient may have an element of medication overuse headache. The submitted clinical records do not adequately document the patients previously failed preventive medications; nor do they establish that the patient has improved with Botox. As such, I have determined the requested therapy is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for residential care for substance abuse treatment. Findings:  The physician reviewer found that the records provided for review document that this patient was having mild withdrawal symptoms on  the date of dispute. However, he was not a danger to himself or others and he was not gravely disabled. He was medically and psychiatrically stable. He was motivated for recovery. The remainder of the patients phenobarbital taper did not require monitoring at a residential level of care. There were no emotional, behavioral, cognitive, or impulsive factors that support treatment at the residential level of care from 1date of dispute forward. He participated in his treatment plan. He could have continued to obtain relapse prevention education and build coping skills on an ambulatory level of care such as intensive outpatient program (IOP) or outpatient with AA support. All told, the residential care for substance abuse treatment from the date of dispute forward was not and is 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 psychiatry with sub-specialty certification 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for intensive outpatient program (IOP) psychiatric level of care services. Applying the level of care utilization system (LOCUS) criteria, treatment with IOP level of care services are supported as medically necessary for treatment of this patients behavioral health issues. The records document the patient was at low risk of harm (score 2) with no prior history of suicide attempts, intermittent suicidal ideation with no plan. The patients functional status was moderately impaired (score 3) as the enrollee can only work for a limited time before becoming overwhelmed. The enrollee lives with parents and remains financially and emotionally dependent on them. The enrollee is able to maintain activities of daily living. The patient demonstrates significant co-morbidity (score 3) with major depressive disorder, generalized anxiety disorder, and an eating disorder. The enrollee does not have medical problems which require intense monitoring. The patients recovery environment is moderately stressful (score 3) as the documentation states that the patient has significant discord with family members. The patient has limited support (score 3) as providers noted that the family dynamic is not supportive of the enrollees recovery. The patient has not been responsive to prior treatment including residential treatment center (RTC), PHP and IOP in 2014 and 2015 (score 3). The patient has demonstrated positive engagement and recovery (score 2) and providers report that the enrollee has been attentive and engaged during treatment. These findings give the patient a composite score of 19, which is consistent with continued IOP treatment. The patient continues to struggle with depression, calorie restriction, family dynamic problems, and emotional dysregulation. Continued IOP will likely prevent the patient from utilizing higher levels of care. Therefore, the requested IOP services are medically necessary for treatment of this patients behavioral health issues.  Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in psychiatry 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 60-year-old female enrollee has requested for vaginal reconstructive surgery for treatment of her lower pelvic pain and urinary incontinence.  Findings:  The physician reviewer found that the literature supporting the use of a gluteal flap in cases of vaginal stenosis is very limited. The incontinence maybe a combination of urge and stress and further medical therapy may be attempted before a sling procedure is performed. In any event, based upon the work-up to date, there is insufficient evidence that the patient requires a sling or gluteal flap for vaginal stenosis at this time.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the patient-activated cardiac recorder implant and monthly event recordings of the device. This patient underwent evaluation with prolonged cardiac monitoring using an implantable cardiac monitor to delineate an etiology for her near syncopal episodes. Transient arrhythmias such as supraventricular tachycardia or bradyarrhythmias could potentially affect therapeutic strategies. Despite the fact that the patient underwent previous radiofrequency ablation of her supraventricular tachycardia, recurrence of this arrhythmia could be responsible for her intermittent symptoms. Reliance on the nature of her symptoms could not differentiate a sinus tachycardia from a reentrant tachyarrhythmia. Further, the patient reportedly could not tolerate the adhesive patches required for routine ambulatory monitoring. Documentation of the precise rhythm disturbance is critical in directing this patients management. An implantable loop monitor with possibly prolonged surveillance was appropriate to arrive at an accurate diagnosis. Therefore, the patient-activated cardiac recorder implant and monthly event recordings of the device were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Findings:  Three physician reviewers found the patient-activated cardiac recorder implant and monthly event recordings of the device were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the patient-activated cardiac recorder implant and monthly event recordings of the device were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.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: Medical Necessity
Decision: Upheld

A 28-year-old female enrollee requested authorization and coverage of saline breast implant surgery. The Health Plan denied the request indicating that the requested surgery is not medically necessary to repair/reconstruct abnormalities in enrollees breasts.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested procedure is not medically necessary.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Botox injection for migraine prevention in combination with Aimovig.Findings:  Two of the three physician reviewers found that clinical experience shows that rational polypharmacy is often more effective than monotherapy. This is a standard of care in headache medicine, as well as other clinical areas, such as hypertension or epilepsy. Botox treatment has been an exclusion in trials of calcitonin gene-related peptide monoclonal antibodies (CGRP mAbs) for reasons of trial design, not for safety. There is evidence in favor of combined therapy with medications of this class. In this patients case, she has benefitted from the combination of Botox injections and Aimovig. There is sufficient support for the requested medication regimen in this clinical setting. Therefore, Botox injection for migraine prevention in combination with Aimovig is likely to be superior over other treatment options. Final Result: The reviewers determined that the requested medication regimen is 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: Physician reviewers 1, 2 and 3 are board certified in neurology 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested three (3) physical therapy visits for treatment of the enrollees status post anterior cruciate ligament (ACL) reconstruction of the right knee.  Findings: The physician reviewer found that the medical literature does not provide conclusive evidence of superiority of home based rehabilitation or supervised physical therapy sessions. Van Melick and colleagues conducted a systematic review of physical therapy after ACL reconstruction. The authors found that owing to a lack of high-quality studies and contradictory results, it is unclear whether there is a benefit of supervised rehabilitation compared to home-based rehabilitation or no rehabilitation at all. A minimally supervised rehabilitation programme may result in successful rehabilitation in specific groups of patients that are highly motivated and live far from a physical therapist. In this case, the patient continues to have functional deficits after 14 post-operative physical therapy sessions. In this clinical setting, one additional physical therapy session is indicated to finalize a home exercise program. In sum, one additional physical therapy session is medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that a portion of the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned.  Credentials/Qualifications: The reviewer is board certified in physical medicine and rehabilitation 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

The parent of a five-year-old male has requested applied behavioral analysis (ABA) therapy with in-home services and in a social setting for treatment of his autism.  Findings:  Three physician reviewers found that there are ample peer-reviewed studies that have reviewed ABA and shown it to be the standard treatment for children with ASD. A few of these references are listed above and clearly support the efficacy of ABA treatment in this patient population. ABA has now become the community standard for treatment of autism in young children by most practicing psychiatrists. The use of this modality in this setting is medically appropriate and is likely to yield superior results compared to any other available intervention.
Appeal type: Medical Necessity
Decision: Upheld

The parent of an 18-year-old male enrollee has requested  for substance abuse intensive outpatient (IOP) services for treatment of the enrollees drug and alcohol addiction and depression. Findings:  The physician reviewer found that there is no documentation that the patient was receiving services at a minimum of three days per week and at least three hours per day, even when he initially began participating in the IOP program. Furthermore, the submitted records consist primarily of weekly notes concerning individual and family therapy. There is not sufficient evidence in the clinical records provided to establish that the patient was in need of IOP services or actually benefited from participation in the program.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Harvoni for 12 weeks. Findings:  The physician reviewer found that According to the 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 non-liver-related conditions. This applies regardless of fibrosis stage or viral load. Per the guidelines, non-cirrhotic genotype 1 patients who have failed peg-interferon and ribavirin should be treated with Harvoni for 12 weeks. These guideline recommendations are based on multiple randomized clinical trials, and the medication is U.S. Food and Drug Administration (FDA) approved for all patients with chronic hepatitis C genotype 1 regardless of fibrosis stage. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:   An enrollee has requested the Veracyte Afirma gene test for evaluation of her medical condition. Three physician reviewers found that while a fine needle aspiration biopsy of a suspicious thyroid nodule is typically an accurate means of assessing whether the nodule is benign or malignant, approximately 15% of fine needle aspiration biopsy results are considered to be indeterminate.  Until recently, the only way to establish whether the nodule was thyroid cancer was via surgical excision, even though the majority of the cases turn out to be benign.  The Afirma Thyroid FNA Analysis utilizes a gene expression classifier in order to help determine the likelihood of malignancy of nodules with indeterminate cytology on fine needle aspiration biopsy, thereby decreasing the need for unnecessary surgeries.  Because it is very sensitive and has a high negative predictive value, a negative Afirma result is rather suggestive of a benign nodule and can therefore preclude such surgical procedures.  All told, the Veracyte Afirma gene test was likely to have been superior over other modalities for evaluating this patient.  Final Result: Three 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 internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism 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.