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

Nature of Statutory Criteria/Case Summary: An enrollee has requested residential treatment for treatment of her behavioral health conditions. The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  Upon presentation, the patient was at a healthy weight.  Her body mass index was within normal limits.  Her vital signs were stable, and she did not have any orthostatic changes.  There was no mention of laboratory abnormalities at the time, and her electrocardiogram was reported to show a normal sinus rhythm.  The following day, the patient was described as motivated for treatment during her first psychotherapy session.  Thereafter, the patient did demonstrate situationally appropriate emotionality largely related to relationships and wariness of relapse, but did not have any difficulty with the therapeutic programming.  Further, during the episode of illness which prompted referral by her psychiatrist, it does not appear that the patient failed a comprehensive eating disorder treatment program, including dietary education, nutritional counseling, family therapy, group therapy, cognitive behavioral therapy and/or interpersonal therapy, delivered in an intermediary setting such as an intensive outpatient or partial hospital program.  This is particularly important in this case as there was no evidence that specialty services provided in a less restrictive setting would have been inappropriate or unsuccessful based on the patients motivation, health and support system.  Finally, considering the patients psychiatric stability, the quest for diagnostic clarification did not require the residential setting to be safely accomplished.  In sum, residential treatment as not and is not medically necessary for the treatment of this patient. 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 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 and prospective authorization and coverage for residential treatment center services provided. Findings:  The physician reviewer found that according to the American Psychiatric Association 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 substance use has been central to his daily routine and contributing to his significant impairment across multiple domains of functionality. He is homeless and unemployed. He has no meaningful sober support network. He frequently blacks out, and has shared needles, overdosed and seized while using. He also has a co-occurring formal thought disorder which represents the most devastating class of psychiatric illnesses. Discharge would have been incongruent with community practice standards. Upon admission the patient was disheveled, anxious, fidgety, and agitated with poor concentration.  In the absence of residential treatment at the time, the patient would have likely relapsed. Thereafter, it appears that the patient struggled to consolidate treatment gains while many medications were trialed. For example, earlier, the patient was agitated, hearing voices and thinking others were hearing voices as well. This prompted the provider to increase the antipsychotic, anxiolytic and wakefulness-promoting medications. The patient began showing signs of improvement a week later. For example, the patient was thinking more clearly and less psychotic. He was planning sober living aftercare and looking forward to his parents visit over the holiday weekend. In sum, the services at issue were and are safe, appropriate and consistent with good practice. The patient has been engaged in active treatment and benefitting from the care. Additionally, the services provided were and are reasonably expected to improve the patients condition and prevent a more serious episode of illness. 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested breast tomosynthesis for evaluation of the enrollees medical condition.  Findings:  Three physician reviewers found that breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than available standard modalities. Tomosynthesis is a technique that was developed as a problem solving adjunct to routine mammography. For patients who have dense breasts tomosynthesis has been shown to have added benefit. The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor.   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 diagnostic radiology 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

A 27-year-old enrollee has requested transcranial magnetic stimulation (TMS) therapy for treatment of his major depressive disorder. Findings:  The physician reviewer found that the peer-reviewed literature supports the requested services in this clinical setting.  TMS therapy has been endorsed by the American Psychiatric Association for the treatment of individuals with depression.  In this particular case, the patient is enduring an acute major depressive episode that is causing significant morbidity and functional impairment.  The patient has pursued other standard therapies used to combat depression.  The submitted documentation indicates that the patient continues to experience significant symptomatology.  Considering the medical records, endorsement from the American Psychiatric Association and expanding peer-reviewed literature base, TMS therapy is an appropriate treatment for this patient.  All told, the requested TMS therapy is medically indicated in this patients case.
Appeal type: Medical Necessity
Decision: Upheld

A 59-year-old male enrollee requested authorization and coverage of  the medication lamisil for the treatment of athletes foot.  The Health Plan denied the enrollees request indicating that the requested treatment is not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer upheld the health plans denial on the basis that the requested medication is not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The mother of an 17-year-old male enrollee has requested residential treatment services for treatment of the enrollees substance abuse.   Findings:  The physician reviewer found that According to the ASAM Criteria and the standard of care for the treatment of substance abuse problems in adolescents, the patient did not demonstrate any behaviors that would require a residential treatment setting. There are also some concerns as to the quality of the treatment rendered at this facility based on the lack of medical oversight. The treatment notes were sparse, with only weekly entries. Nonetheless, a complete review of the clinical record does not provide evidence of serious medical, emotional or behavioral conditions that required 24-hour monitoring or supervision. The patient could have been appropriately treated at an outpatient level of care in a chemical dependency program supervised by a psychiatrist.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a five-year-old male has requested occupational therapy, sensory integration, social cognitive speech and language therapy for treatment of his autism. Findings:  The physician reviewer found that occupational therapy has been shown to result in significant improvement in activities of daily living in this setting (Case-Smith and Arbesman). Occupational therapy has been requested in this case to address the patients tactile, vestibular and proprioceptive function and is a medically appropriate modality to address deficiencies in these areas (Zingerevich, et al). The requested sensory integration therapy, Fazlioglu and Baran evaluated children between 7 and 11 years of age with autism and the use of a sensory integration program and found statistically significant improvements in the group of patients receiving sensory integration therapy. Pfeiffer, et al. also studied the effectiveness of sensory integration intervention compared to a fine motor treatment group. The results identified significant positive changes in both groups, however, more significant changes occurred in the sensory integration group, and a significant decrease in autistic mannerisms also occurred in the sensory integration group. This would suggest that sensory integration is helpful in children with autism and is medically indicated to address this patients auditory, tactile and oral motor deficits.The goal of early identification of speech and language problems is to initiate early intervention, which has been shown to improve outcomes for children who have ASD. On average, the children who received speech therapy showed a significant increase in expressive language skills. In addition, occupational therapy combined with speech and language therapy can focus on oral-motor intervention to reduce tactile sensitivity and increase muscle tone in order to enhance language development.
Appeal type: Experimental/Investigational
Decision: Overturned

A 51-year-old female enrollee has requested Valtrex/valacyclovir (4 grams per day) for treatment of her herpes simplex virus.  Findings:  The physician reviewer found that Valtrex is the standard treatment for the treatment of herpes, and in this case, the dosing is at issue.  However, a range of different dose regiments is not unusual for the use of antiviral medications. The recommended Valtrex dosage and length of treatment depends on several factors, such as patient age, concurrent medications, renal status, and the actual indication for use. Although uncommon, it is also documented that patients can have refractory herpes simplex virus disease, and can have resistance to traditional treatment dosing.  Treatment in these patients with refractory disease is limited. In this patients case, she has responded to valacyclovir, 4 grams per day.  All told, the requested Valtrex/valacyclovir, 4 grams per day, is likely to be the most efficacious treatment for this patient.
Appeal type: Medical Necessity
Decision: Upheld

An 82-year-old female enrollee has requested for a follow-up colonoscopy for screening of her medical condition. Findings:  The physician reviewer found that the guidelines also state that if a follow-up colonoscopy is normal, or even if it shows one or two tubular adenomas, then the next colonoscopy should be in five years time. Thus, based on national guidelines, and the lack of objective data regarding her recent change in condition, a follow-up colonoscopy is not medically necessary for this patient.
Appeal type: Medical Necessity
Decision: Overturned

An enrollee has requested authorization and coverage for corneal transplant with laser to be performed at one location, instead of two. The submitted documentation supports the medical necessity of the requested services. While there is a paucity of studies that have specifically compared laser keratoplasty procedure performed at two different sites versus one site, transporting the patient from one site to another during the procedure does add a small risk to the procedure. Therefore, in order to minimize risk of any harm to the patient, the one site procedure is recommended. Thus, the requested corneal transplant with laser to be performed at one location, instead of two, is medically necessary for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for the LINX procedure (esophageal sphincter augmentation device) for treatment of her gastroesophageal reflux disease (GERD).Findings: Three physician reviewers found that the request for the LINX procedure (esophageal sphincter augmentation device) is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The patient presents with a diagnosis of GERD based on pH recording but whether she is medically refractory to acid blocker drugs cannot be determined. The records do not specify the PPI brand, dose, or duration. Also, implantation of LINX in this clinical setting must be approached with caution given her documented solid food dysphagia and known history of Barretts. LINX may exacerbate dysphagia, and is not indicated for patients with Barretts esophagus. As such, the requested procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.  Final Result: All three physician reviewers determined that the requested procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: All three physician reviewers number are board certified in internal medicine with sub-specialty certification in gastroenterology and are actively practicing. The reviewer 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: The parent of an enrollee has requested reimbursement for inpatient detoxification services for treatment of his alcohol dependence and alcohol withdrawal. Findings:  The physician reviewer found that on admission, the patients physical examination was essentially within normal limits. The patient had an intact neurological examination, review of systems was described as unremarkable, and he was noted to be medically stable. Nursing notes indicate that he was fully oriented, neat and clean, and had no suicidal or homicidal ideation. He was described as anxious and cooperative. Group notes document that he described himself as happy and relaxed. Other progress notes indicate that he slept seven hours per night and ate all of his meals. He was described as coping well. He was able to manage his own activities of daily living, and there is no description of delirium tremens, seizures, blackouts, or disorientation. The patient did not have any significant alcohol withdrawal symptoms and was a candidate for treatment in a less restrictive setting. 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 psychiatry with sub-specialty certifications in child and adolescent psychiatry and 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: Upheld

The parent of a 16-year-old female enrollee has requested  for a custom anterior cruciate ligament (ACL) brace  for treatment of the enrollees medical condition status post ACL repair.  Findings:  The physician reviewer found that knee braces have been used for some time following ACL reconstructive surgery, there is little evidence to support the practice (Wright, et al). In addition, there is a paucity of scientific data demonstrating that the use of braces prophylactically to reduce injuries to knee ligaments is effective (Garrick and Requa). No significant protection could be identified, and there may be negative effects associated with brace use (Najibi and Albright). This lack of evidence of benefit has been reported for other contact sports, such as football, and hockey (Tegner and Lorentzon).
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Decision DX Melanoma Assay for evaluation of the enrollees malignant melanoma.Findings:  The physician reviewer found that the prognosis of cutaneous melanoma has classically been determined by applying the staging system spelled out by Balch. Mitotic index may also add a bit more to these statistics.  By Balch staging, this melanoma would be staged as a T3aN0, or stage IIA. This would be expected to have a ten-year survival of approximately 64%.  Decision DX is a study of 31 genes in an individuals melanoma cells.  It then classifies that particular melanoma as either Class 1 (with a 97% disease free rate at five years) or Class 2 (with a 20 to 30% disease free rate at five years). Good correlation between prognosis and Decision DX has been reported in patients undergoing sentinel node sampling, as has this patient. However, it is not clear how the Decision DX five-year data compares to the ten-year Balch data, and whether it can be used to make clinical decisions. 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 sub-specialty certification in medical oncology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for knee surgery for treatment of the enrollees right knee pain. Findings: The physician reviewer found that this patient has a degenerative tear of the medial meniscus, a high BMI, and unremarkable radiographs or evidence of mild osteoarthritis. In the medical literature, one study noted that higher BMI in middle aged patients with isolated medial meniscal tears and unremarkable radiographs may predict more advanced chondral lesions at arthroscopy. The literature advises against partial medial meniscectomy in the presence of chondral lesions because of adverse outcomes. In this case, the patients pain is anterior, across the patella radiating in a transverse fashion and is more likely to be due to the MRI evidence of patellofemoral chondromalacia that was noted three years ago. This has likely advanced and the outcome of any surgical procedure will not be favorable. According to another study, degenerative medial meniscal tears, in the presence of osteoarthritis, can only marginally benefit from arthroscopic debridement over intraarticular steroid injections in short-term follow up. In patients with posterior horn degenerative tears in the presence of obesity and osteoarthritis, surgical interventions are not recommended. Weight loss should receive primary consideration. Final Result: The reviewer determined that the requested surgery 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 orthopedic 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: Upheld

A 50-year-old female enrollee has requested transcranial magnetic stimulation (TMS) therapy for treatment of her bipolar disorder.  Findings:  Two physician reviewers found that the US Food and Drug Administration (FDA) provided approval for TMS for the treatment of major depressive disorder. Subsequently, the American Psychiatric Association (APA) endorsed TMS for the acute phase treatment of major depressive disorder. However, the recommendation does not include an indication for treatment of bipolar disorder. Consistent with these guidelines, the requested TMS therapy is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy including olanzapine/fluoxetine combination, quetiapine, tricyclic antidepressants, monoamine oxidase inhibitors, electroconvulsive therapy, or more intensive psychotherapy.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for dual agent chemotherapy with paclitaxel and bevacizumab. The submitted documentation fails to demonstrate the medical necessity of the requested medication regimen. The combination of paclitaxel and bevacizumab is not considered standard of care in the treatment of recurrent or progressive endometrial cancer. In addition, this patient has progressed on a dual regimen containing paclitaxel. Single agent bevacizumab is considered a standard of care in the treatment of patients with progression on other cytotoxic agents. The medical evidence does not support the combination of paclitaxel and bevacizumab in this setting. Therefore, dual agent chemotherapy with paclitaxel and bevacizumab is not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medication regimen 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 medical oncology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.