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

Findings:  The physician reviewer found that The patients parent has requested authorization and coverage for occupational therapy services (twice a week). As noted in the medical literature, patients with ADHD manifest behavioral and functional impairments, as well as social and psychological issues that are problematic for participation and academic learning (Ianni, et al.). Patients in this subset also demonstrate delays or inability to meet expected milestones in different developmental domains. As a result, multidisciplinary team involvement including neuropsychology, occupational and speech therapy, and social work may be required to maximize the patients quality of life. Acquisition of effective motor skills is important to perform language and communication, academic learning, social interaction, and self-care functions. Occupational therapy trains patients to effectively interact with their environment and engage in daily activities. In this patients case, occupational therapy is indicated to  maximize functional independence and participation in the school, home, and community environments. The potential benefits of occupational therapy include stimulation of vocalization and language, improved toleration of touch, sound, vestibular stimuli, as well as improved self-care, safety awareness, and upper extremity motor coordination. The occupational therapy interventions including family centered therapy with adaptation and compensation strategies are the appropriate therapeutic interventions for this patient. Moreover, the requested occupational therapy services are in accordance with the generally accepted standards of mental health and substance use disorder care, clinically appropriate in terms of type, frequency, extent, site, and duration, and not primarily for the convenience of the patient or provider. Given these findings, the requested occupational therapy services (twice a week) 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.
Appeal type: Experimental/Investigational
Decision: Overturned

The parent of a 15-year-old female enrollee has requested for diagnostic testing for inflammatory bowel disease (IBD) markers for evaluation of the enrollees abdominal pain. Findings:  Three physician reviewers found that diagnostic testing for IBD markers is rarely indicated for patient management. However, this case is exceptional in that there is abnormal histology and radiology to suggest the patient has IBD, but there is not enough data available to give a conclusive answer. This is important for several reasons. If the testing is negative then stopping steroids (Entocort) would be reasonable and beneficial to the patient. If the tests are positive and clarify the type of IBD she has, this will be useful to plan for therapy in the future and anticipate potential problems associated with IBD. Thus, the requested diagnostic testing is likely to more beneficial for evaluation of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The parent of a female enrollee has requested reimbursement for neuropsychological testing provided for evaluation of the enrollee, who has a history of academic struggles and underperformance. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  The description of her behavior noted during the testing sessions meets most of the diagnostic criteria for the diagnosis of attention deficit/hyperactivity disorder.  Therefore, simple observation of this patient by the parents and teachers as reported on an accepted attention deficit/hyperactivity disorder rating scale would have provided the same information as the hours of testing that were performed.  If there were any doubt, the patient could have been administered the Test of Variables of Attention (TOVA) test only.  TOVA is a good test of the patients ability to focus and sustain attention.  The patients performance on this test was highly supportive of the attention deficit/hyperactivity disorder diagnosis.  Thus, there is a lack of support for the services at issue in this clinical setting.  All told, neuropsychological testing provided was not medically indicated for the evaluation of this patient. Final Result: The reviewer determined that 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 psychiatry with sub-specialty certification in child and adolescent 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

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for 30 treatments hyperbaric oxygen therapy (HBOT) in a multi-chamber. This patients records document a history of gender affirming surgery with body contouring and fat grafting. The patient underwent treatment with HBOT on various dates. As noted by medical literatures, HBOT is a medical technique which delivers oxygen at ambient pressures to increase the amount of dissolved oxygen in the blood and oxygen distribution to tissues. On review of the available medical literature, HBOT was not medically necessary following the body contouring and fat grafting performed in this patients case. There is insufficient evidence demonstrating improved patient health outcomes with HBOT for patients in the post-operative setting after body contouring and fat grafting procedures. Researchers concluded that HBOT can be effective for patients with compromised skin grafts and skin flaps. This procedure notes and physical examination reports did not document concern for any failed hypoxic skin grafts. Given these findings, the 30 treatments HBOT in a multi-chamber were not medically necessary for treatment of this patient.Final Result: The reviewer determined that the services at issue were not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be not. Credentials/Qualifications: The reviewer is board certified in family medicine with subspecialty certifications in preventive medicine and undersea and hyperbaric 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: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for high-intensity focused ultrasound (HIFU) for treatment of the enrollees prostate cancer. Findings:  Three physician reviewers found that HIFU consists of focused ultrasound waves, emitted from a transducer, that cause tissue damage by mechanical and thermal effects as well as by cavitation. The goal of HIFU is to heat malignant tissues so that they are destroyed by coagulative necrosis.  HIFU has been increasingly been used for treatment of localized prostate cancer within the last decade. It has the theoretical potential of decreasing gastrointestinal, genitourinary and sexual toxicity. Potential candidates are patients with low-risk to moderate-risk prostate cancer. The available literature mainly consists of prospective case series and retrospective studies showing short to intermediate term outcomes for localized prostate cancer. However, there is a lack of controlled trials available for analysis, and a paucity of long-term survival data is available. The National Comprehensive Cancer Network guidelines note other emerging local therapies, such as high-intensity focused ultrasound (HIFU) and vascular-targeted photodynamic (VTP) also warrant further study. American Urological Association/American Society for Radiation Oncology/Society of Urologic Oncology guidelines note clinicians should inform low-risk prostate cancer patients who are considering focal therapy or high-intensity focused ultrasound (HIFU) that these interventions are not standard care options because comparative outcome evidence is lacking. Final Result: The reviewers determined that the services at issue were 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: Reviewers 1, 2 and 3 are board certified in urology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:   An enrollee has requested a 12-week course of Sovaldi and Daklinza for treatment of her hepatitis C.  Findings:  The physician reviewer found that according to joint guidelines issued by the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America, all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions.  Patients with cirrhosis are considered to be highest priority for therapy.  The patient is interferon-ineligible due to a pre-existing condition.  In cirrhotic, treatment-naive, genotype 3 patients, therapy is recommended with Sovaldi and Daklinza (daclatasvir) for 24 weeks (Nelson, et al).  Per the guidelines, Sovaldi and ribavirin for 24 weeks is an alternative regimen only for treatment-naive genotype 3 patients who are daclatasvir-ineligible and interferon-ineligible.  The patient is not ineligible for daclatasvir.  In sum, treatment with Sovaldi and Daklinza for 24 weeks is the recommended treatment regimen for patients such as this patient.  There is a lack of support for the requested 12-week course duration of Sovaldi and Daklinza; therefore, the requested medications are not medically necessary for the treatment of this patients hepatitis C virus.  Final Result: The reviewer determined that the requested medications 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 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

Nature of Statutory Criteria/ Case Summary:  The enrollees parent is requesting reimbursement for residential treatment center (RTC) level of care services. The enrollee has diagnoses of autism spectrum disorder (ASD), attention deficit hyperactivity disorder (ADHD), and major depressive disorder (MDD). He was diagnosed with ASD at age three and enrolled in an Individualized Education Program (IEP) from age three until age ten, with full inclusion in a classroom with an aide. His parents removed him from public school due to behavioral issues; after which he was home schooled.  He was verbally and sometimes physically abusive toward others.  He was admitted for psychiatric hospitalization due to holding a knife to his chest.  He entered the RTC program last fall.  His initial psychiatric assessment noted his last suicidal and homicidal ideations were two months prior.  He continued his home medications. Dose titration of Abilify was initiated and tolerated. He appeared ready to transition to a lower level of care and was discharged. The Child and Adolescent Level of Care Utilization System (CALOCUS), level of care assessment tool, was utilized to support accurate level of care determination. The enrollees composite CALOCUS score is 19, which correlates with intensive outpatient services. Medical evidence does not support the services at issue in this clinical setting.Final Result: The reviewer determined that the requested services were not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in psychiatry and child and adolescent 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

This 51-year-old female with morbid obesity was seen and evaluated by a vascular surgeon for painful lumps in the leg. There was no venous or arterial disease identified, but as a precautionary measure, the vascular surgeon ordered an MRI, which was negative.There is no evidence of vascular disease in this patient. Clinically, the patients condition is due to obesity, most likely lipedema. Furthermore, there is no evidence the patients condition requires management by a vascular specialist. Based upon the information provided, the patient can be safely and effectively managed by her primary care physician. Therefore, I have determined that the requested referral is not medically necessary for the evaluation of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

The patient is an 18-year-old female with a history of fatigue and sleepiness. Her psychiatrist indicates the patient was tried on a number of medications without benefit and that Provigil has been the only medication that has been effective for the patients condition. Apparently, the psychiatrist wants to increase the patients prescription to 200 mg a day. The Health Plan has denied authorization for Provigil.Although there is evidence supporting the use of Provigil as an antidepressant adjunct and for treatment of residual fatigue, no objective evidence has been submitted demonstrating Provigil is necessary or indicated for this patient. There are other approved psychostimulants available for treatment of the patients condition that have not been attempted. Furthermore, based upon the information provided, it appears other causes of the patients fatigue have not been ruled out. Because of the need to rule out other causes of the patients fatigue and the availability of other approved psychostimulants, which apparently have not been tried, I have determined the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Repatha SureClick. Findings:  The physician reviewer found that the documentation provided does not support the medical necessity for the requested medication in this clinical setting. Based on the records provided, the patient has no current angina; mild creatine kinase (CK) elevation; and low density protein (LDL) cholesterol of 72 mg/dl on maximally tolerated rosuvastatin medication at 5 mg/day combined with ezetimibe 10 mg/day. The patients records indicate an LDL close to the recommended goal. Studies have shown that mild CK elevation is not a contraindication to continuing statin medication. Moreover, the patients medical records do not document his intolerance to the currently prescribed lipid medications. Both have been demonstrated to have outcome benefits. Since the patients medical records do not confirm a contraindication to the currently prescribed lipid medications, or intolerance to the currently prescribed lipid medications, the requested medication is not medically necessary. Also, the patient has experienced effective lipid lowering to a goal on current medications. Medical studies support the use of proprotein convertase subtilisin/kexin type 9 inhibitors for patients who are unable to take statin medications and/or need additional reduction in LDL cholesterol. In this patients case, his records do not document that he is unable to take statin medications or that he needs additional reduction in his LDL cholesterol. As such, Repatha SureClick is not medically necessary for the treatment of this patient. Final Results: 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 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 30-year-old male enrollee requested authorization and coverage of gastric bypass surgery for the treatment of morbid obesity and comorbidity conditions.  The health plan denied the enrollees request indicating that the requested procedure is not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer overturned the health plans denial on the basis that the requested procedure is medically necessary depending upon the results of a psychological evaluation.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for continuous treatment at a tertiary care center. The Health Plan has denied this request indicating that the requested services are not medically necessary for treatment of the enrollee who has a history of cutaneous mastocytosis.There is support in the documentation provided for the requested services in this clinical setting. This patient was diagnosed with a form of cutaneous mastocytosis. At this time, there is no evidence of systemic involvement but the patients medical condition is a persistent concern requiring careful examination and staging of the patient. Based on the documentation provided, it appears the etiology of the patients condition was initially unknown. The patient sought a second opinion from a hematologist/oncologist and has been receiving treatment from the same provider for approximately three years. At this time, the patient has requested that her care be continued with the same provider. In this patients case, the documentation provided supports that this patient should continue to receive treatment at a tertiary care center capable of proper staging work up. The records demonstrate the medical necessity for continuous therapy at a tertiary care center for the treatment of this patients medical condition.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 internal medicine with sub-specialty certification in medical oncology and hematology 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

An 18-year-old male enrollee requested residential treatment center (RTC) services for medical treatment of the enrollees behavioral health condition.  Findings:  The physician reviewer found that the patient was not suicidal, homicidal or engaging in self-harm. In addition, he was not at risk of withdrawal. He was medically stable and not at risk of harm. There was no interference to his addiction recovery. He had minimal impairment in social functioning and no difficulties with activities of daily living. He was ready for change and needed limited support to maintain abstinence. His family could have provided a supportive environment for recovery. Given all of the above, his condition did not meet the medical necessity criteria for residential level of care and could have safely been treated at a lower level of care. Based on the medical literature cited above and the documentation submitted for review, RTC level of care was not medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 64-year-old female enrollee has requested the combination of Sovaldi and Olysio for medical treatment of her hepatitis C.  Findings:  Two physician reviewers found that in this patients case, the requested medication combination is not likely to be more effective than other treatment options.  She has minimal hepatic fibrosis per her biopsy.  There is no updated pathology or non-invasive fibrosis marker such as FibroSure or transient elastography.  Although she is likely to eradicate the virus on the combination of Olysio and Sovaldi, the actual benefit to her is negligible based on her level of fibrosis.  Per the medical records, she has no evidence of extrahepatic manifestations of hepatitis C such as cryoglobulinemia.  All told, the superior efficacy of the requested combination of Sovaldi and Olysio has not been established.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for tertiary level of care services for eye care. The records provided for review document that this patient has a number of active clinical problems that are likely to affect her eye health. The provider charted a history of thyroid eye disease without significant proptosis and dry eye disease with concomitant signs of inflammation. In addition, the patient has a history of positive anti-nuclear antibody (ANA), although a low titer, which is consistent with an autoimmune process. Thyroid eye disease is oftentimes associated with dry eye disease. The provider noted concern for Sjogrens syndrome, which may be difficult to diagnose in the early stages, but there may be subtle signs on physical examination. Based on these ongoing active issues, it is medically reasonable for this patient to undergo a tertiary level consultation for her eye disease. Given these findings, the requested tertiary level of care services for eye care 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 ophthalmology 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.