Persius/imr-appeals huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for advanced lipoprotein testing. Based on the records provided, this patient presented to his provider with some cardiovascular risk given his history of hypertension. In this circumstance, guidelines for the management of cardiac risk established by the American College of Cardiology Foundation (ACCF) and American Heart Association (AHA) do not support routine advanced lipoprotein testing (Greenland, et al.; Stone, et al.). These guidelines currently do not recommend routine performance of specialized tests in the context of assessing coronary risk including lipoprotein associated phospholipase A2, sub-classifications of low density lipoprotein (LDL) cholesterol, high density lipoprotein (HDL) cholesterol subclasses, lipoprotein (a), Apo A-1, and homocysteine. In addition, treatment changes or additions based on the results of screening with these specialized tests has not been shown to improve cardiac outcome incremental to that achievable by treatment based on standard risk factor profiling and basic lipid analysis. Therefore, the advanced lipoprotein testing 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 advanced lipoprotein testing 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 services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in internal medicine with subspecialty 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: Overturned

A 26-year-old male enrollee has requested Tysabri injections for treatment of his multiple sclerosis.  Findings:  The physician reviewer found that based on review of the available records, this patient has relapsing-remitting multiple sclerosis, with worsening symptoms while on high dose interferon therapy (Rebif). Thus, it is medically necessary for this patient to be treated with another disease modifying therapy. The medical literature supports the use of Tysabri as a second-line agent in patients with aggressive disease who have failed a first-line therapy. In addition, Tysabri has been demonstrated to be therapeutic in patients with Crohns disease, which is one of the patients conditions. As this patient has relapsing-remitting multiple sclerosis that has not been adequately controlled with Rebif, and has difficulty with self injection, Tysabri is a reasonable treatment alternative. Further, Tysabri is considered the most effective therapy currently available and is widely used as a second-line agent in similar clinical situations. Therefore, the requested medication is medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested Belsomra for treatment of his medical condition. Findings: The physician reviewer found that based on the documentation submitted for review, the medication at issue was not and is not medically necessary for treatment of the patients medical condition. Most hypnotics have not been studied for long-term control of insomnia. However, extended-release zolpidem has been studied for this indication (Krystal, et al). The study by Krystal and colleagues found that the efficacy of three to seven nights per week dosing of zolpidem extended-release 12.5 mg for up to six months provided significant and sustained improvements in sleep onset, sleep maintenance, next-day concentration, and morning sleepiness. In this case, the documentation submitted does not demonstrate a trial of a benzodiazepine agonist such as zolpidem or zaleplon have been tried. Baclofen belongs to a different drug class, and there is no known cross-reactivity between the two classes in precipitating migraine headaches. Furthermore, non-pharmacologic options such as cognitive behavioral therapy for insomnia (CBTI) that have not been documented as trialed in this case. Given that there are effective and safe options available; Belsomra has not been established as medically necessary for treatment of the patients medical condition.  Final Result: The reviewer determined that the medication at issue was not and 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 neurology with sub-specialty certification in sleep 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: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for inpatient hospitalization services. The Health Plan has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees cellulitis, and flank/groin pain. At issue in this case is whether the inpatient hospitalization services provided were medically necessary for treatment of the enrollees medical condition.Inpatient hospital care is necessary when the patients signs, symptoms and general medical condition can only be managed safely in an acute inpatient setting; when the patient requires diagnostic studies in an inpatient setting; or if it is medically necessary for the patient to remain in the acute inpatient setting. In this case, the patient was admitted in stable condition and could have been treated at a lower level of care. He did not have a fever or elevated white blood cell count.  There was no indication in the records that he had failed treatment as an outpatient.  He was able to ambulate. His pain was reasonably controlled with oral medications, and he was hemodynamically stable. Therefore, the inpatient hospital admission was not medically necessary.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 upheld.Credentials/Qualifications: The reviewer is board certified in internal 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: Upheld

The patient is a 64-year-old man with arthritis of the hip who is requesting minimally invasive hip replacement surgery. The Health Plan has denied the patients request on the basis that the requested procedure is not medically necessary for treatment of the patients condition.The patients medical condition requires hip replacement. The standard procedure involves a fairly large incision. Some surgeons are now performing the procedure with annular incisions, some with incisions of one to two inches in length and special instruments for such small openings. To date, it has not been shown that there is any increased benefit from smaller incisions on a long-term basis. Furthermore, there are reports of complications with smaller incisions due to an inability to visualize the entire hip. The submitted information does not demonstrate that the patient requires minimally invasive hip replacement surgery. Although the requested procedure involves a smaller incision, the surgery itself is identical to routine hip replacement. Thus, the requested procedure is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for anterior optical coherence tomography. Findings:  Two of the three physician reviewers found that anterior segment optical coherence tomography is an imaging technique that can be used to examine the structures in the anterior segment. It has been reported to be useful for evaluating the anterior chamber angle. Per the medical evidence, the standard technique for evaluating a patient with narrow angles is gonioscopy. In this case, there is no documentation that a gonioscopy was performed. Studies have not found anterior segment optical coherence tomography to be a replacement for gonioscopy. In sum, anterior optical coherence tomography was not likely to have been of greater benefit than other methods of evaluating this patient. Final Result: The reviewers determined that the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in ophthalmology 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: Experimental/Investigational
Decision: Overturned

A female enrollee requested magnetic resonance imaging (MRI) of the breast for medical evaluation of her breast cancer.  Findings:  Three physician reviewers found thatbased on the documentation submitted for review, the patients lifetime risk is 20-25% due to the family history described in the records submitted. All told, the requested diagnostic procedure is likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of enrollee has requested reimbursement for the intensive outpatient program (IOP) services provided. The Health Plan has denied the request as not medically necessary for the patients behavioral health condition. At issue in this case is whether the IOP were medically necessary for the treatment of the enrollees behavioral health condition.The American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists Child and Adolescent Level of Care Utilization System (CALOCUS) provides a reliable framework for determining the appropriate level of care for adolescents needing mental health treatment. Using CALOCUS, treaters score patients on a scale of 1-5 using a six-pronged Dimensional Rating System. The six dimensions include: (1) risk of harm; (2) functional status; (3) medical, addictive and psychiatric comorbidity; (4) recovery environment (a. stressors and b. supports); (5) treatment and recovery history; and (6) engagement. The composite score is then used to determine the level of care needed.  Regarding the six CALOCUS dimensions, the patient has a significant risk of harm, cutting on herself and her history of verbal aggression and impulsivity (score = 3). Regarding functional status, she has moderate impairment of function in that she is failing in school and has daily emotional instability (score = 3). There are no comorbidities noted (score = 1). The patient has a moderately stressful recovery environment due to the impending relocation and her fear of relationships becoming emotionally distant (score = 3). Her parents were involved and supportive (score = 2). The patient has had only an equivocal response to treatment, which is manifested by her expressed ambivalence toward her attacker, persistent emotional instability, and her impulses to put herself into risky situations (score = 3). The patient appears to display an obstructive engagement with her treatment with rationalization and denial (score = 3). The patients parents appear to take a constructive position in support of treatment with active engagement in therapy (score = 2). For a CALOCUS composite score of 20, the recommended level of care is high-intensity outpatient therapy. Therefore, the IOP services provided were medically necessary for this patient.Final Result: The reviewer determined that the requested services were medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in psychiatry with subspecialty 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 parent of a minor enrollee has requested authorization and coverage for 172 hours per month of direct one-to-one applied behavioral analysis (ABA) therapy, 14 hours per month of supervision, and two hours per month of parent training. Medical literature regarding the intensity of ABA therapy required for optimal outcomes in children with autism spectrum disorder show that no correlation between the number of hours provided per week and outcomes. Medical literature further indicate that the age at which ABA therapy was started and duration of treatment was correlated with outcome. This patient has been documented as making significant progress in almost all areas since starting ABA therapy in October 2017. The Health Plan has approved the patient for 96 hours per month of direct one-to-one ABA services, which are appropriate given this patients current behavioral issues. Thus, the requested services of 172 hours per month of direct one-to-one ABA therapy, 14 hours per month of supervision, and two hours per month of parent training are 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 reviewer is board certified in pediatrics and neurology with special qualification in child neurology 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 54-year-old female enrollee has requested for IVIG therapy for treatment of her hypogammaglobulinemia. Findings:  The physician reviewer found that the patient does not meet standard criteria for treatment with IVIG therapy. Although she has documented low levels of IgG, she has not been diagnosed with a specific immunodeficiency. IVIG therapy is not indicated for all causes of hypogammaglobulinemia. Laboratory testing did not demonstrate an inability to respond with IgG antibody production after antigenic challenge against Diphtheria, Tetanus toxoid or pneumococcal vaccine. The testing was initiated, but no post-antigenic values were reported prior to treatment with IVIG.
Appeal type: Medical Necessity
Decision: Upheld

A 45-year-old male enrollee, who had a shoulder injury, has requested authorization for physical therapy services as well as prospective authorization for additional physical therapy services.Findings:  The physician reviewer found that this patient had sufficient physical therapy prior to the specified date to be able to establish a home program. The therapy did not have an appropriate short or long-term goal that would meet criteria for anything beyond maintenance treatment and passive modalities.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for continued skilled nursing facility care for treatment of the enrollee, who has a history of a stroke. Findings:  The physician reviewer found that chronic pressure ulcers generally require multimodal interventions for resolution, including nutritional support, pressure relief, wound debridement and appropriate topical wound management.  The records in this case indicate that the patients pressure ulcers have been improving slowly on the current treatment regimen, which includes up to twice daily routine topical product application and dressing changes. The records do not indicate that the patient has any pressure ulcer management needs that could not be provided in the community setting with home nursing visits and outpatient follow up.  The prognosis for her clinical course and outcomes would remain guarded on account of her underlying conditions which include old stroke, multiple limb contractures and deconditioning. Ongoing skilled nursing facility level care would not have been expected to marginally improve clinical course or outcomes over community-based care.  The records do not otherwise document services that the patient needed in an inpatient setting that could not otherwise have been delivered in the community setting. 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 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: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential, substance use disorders, rehabilitation, adult and geriatric treatment provided .Findings:  The physician reviewer found that The documentation provided for review supports the medical necessity of the residential treatment in dispute. The American Psychiatric Association (APA) states that Residential treatment is indicated primarily for individuals who do not meet clinical criteria for hospitalization but whose lives and social interactions have come to focus exclusively on substance use and who currently lack sufficient motivation and/or substance-free social supports to remain abstinent in an ambulatory setting. In this case, the patients alcohol use disorder was complicated by co-occurring depression and anxiety. 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 . The patients alcoholism was central to her daily routine and contributed to her significant impairment across multiple domains of functionality. Despite an alcohol-related arrest and facing occupational and legal uncertainty, she demonstrated minimal motivation for recovery at the outset. The patient lived alone and was estranged from her family. The patient was unable to achieve sobriety in her environment. The patient was struggling with anxiety and depression despite outpatient psychiatric services. The patient had significant medical comorbidity as well. During the disputed time frame, the patient was engaged in active treatment. The patient was prescribed an anti-craving medication in addition to the full array of non-pharmacologic interventions afforded by the setting. Based on the documentation submitted for review, the services at issue were safe, appropriate and consistent with good practice, while the duration of treatment aligned with community standards. Additionally, the services provided were reasonably expected to improve her condition and prevent a more serious episode of illness. Accordingly, the residential, substance use disorders, rehabilitation, adult and geriatric treatment provided during the dates of dispute16 was medically necessary for the patients medical condition. 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 is board certified in psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Octagam intravenous immunoglobulin (IVIG). Findings: While the medical records do indicate low pneumococcal antibody titers for this patient, there is a lack of documentation of whether pneumovax was administered prior to checking the patients antibody titers and when the vaccine was administered in relation to the blood work. Without this information, the patients low antibody titers do not support an indication for treatment. Overall, this patient does not qualify for the diagnosis of specific antibody deficiency. Furthermore, the medical records report a history of recurrent infections. However, the records do not document a history of the type of specific infections that qualify for IVIG replacement therapy in the treatment of specific antibody deficiency. A history of small intestinal bacterial overgrowth (SIBO) and mast cell activation syndrome (MCAS) does not support an indication for IVIG treatment as these are not manifestations of specific antibody deficiency. Given these findings, the requested Octagam IVIG is not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in internal medicine with subspecialty certification in allergy and immunology 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.