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

A 47-year-old female enrollee requested substance abuse residential treatment center (RTC) level of care services for treatment of the enrollees substance abuse.  Findings:  The physician reviewer found that substance abuse RTC services were not medically necessary for treatment of the patients medical condition. At the time of admission, the patient was stabilized on a Librium taper. There was no evidence of suicidal/homicidal ideation, intent, or plan. There was no evidence of risk of danger to self or others. There was no psychotic ideation in any modality. The patients medical and psychiatric medication regimen and any adjustments did not require 24-hour supervision and could have been managed on an outpatient basis.  She had not attempted a lower level of treatment such as intensive outpatient or outpatient. She described her husband in positive terms and has a good relationship with her children. All told, the patient did not meet the medical necessity criteria for residential treatment level of care and could have been treated at a lower level of care such as intensive outpatient programming (IOP) or an outpatient office based treatment, in conjunction with community based services such as a 12-step program along with a sponsor.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 20 year old male who underwent surgical removal of four impacted third molars in January 2006 at the age of 19. The procedure was performed under general anesthesia. The Health Plan has denied reimbursement for the general anesthesia services indicating the services were not medically necessary.The question to be answered is whether it was medically necessary to have general anesthesia for the surgical removal of four impacted third molars. Medical necessity for general anesthesia is determined either by the complexity of the surgical procedure being performed or by the presence of an underlying medical condition for which general anesthesia is required. Review of the submitted records indicates the patient was a healthy, American Society of Anesthesiology Class I, 19-year-old male with no significant medical or emotional conditions that necessitated general anesthesia. In addition, the submitted records indicate that it required 14 minutes for the surgeon to surgically remove all four impacted wisdom teeth. This strongly suggests that there was no unusual complexity to the surgical procedure that would necessitate general anesthesia. Consequently, medical necessity for general anesthesia has not been established.For the reasons stated above, I have determined the services at issue were not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

A 48-year-old female enrollee has requested chiropractic care/physical therapy for treatment of her low back pain.  Findings:  The physician reviewer found that chiropractic techniques are commonly applied for the treatment of back and neck pain and have been rated very helpful by patients.  The literature supports the effectiveness of manual therapy/spinal manipulative therapy for the management of chronic back pain. In this case, the patient has a history of chronic back pain. The records indicate that she responded to manual therapy with gradual improvement in her pain rating scores. The treatments were consistent with standard practice and have benefitted the patient. All told, past chiropractic care/physical therapy was medically indicated for this patient.
Appeal type: Medical Necessity
Decision: Overturned

The enrollee is requesting authorization and coverage for the medication Cimzia. The enrollee has a history of type 2 diabetes mellitus and necrobiosis lipoidica diabeticorum. She has been experiencing exacerbations of necrobiosis lipoidica diabeticorum, with red nodules, itching, and pain. She has tried multiple medications, and none of these have relieved her symptoms. A case study demonstrated successful treatment of necrobiosis lipoidica with adalimumab, an anti-tumor necrosis factor medication. However, researchers report a larger sample size is needed, and the response to the medication in both diabetic and non-diabetic individuals requires further study. Literature shows necrobiosis lipoidica is a difficult disease to manage, despite a large number of treatment options. Randomized control trials are lacking to evaluate the many treatment methods and establish a standard plan of care. This enrollee tried and failed multiple medications; including three anti-tumor necrosis factor medications. The records do not provide sufficient information as to why an additional anti-tumor necrosis factor medication would be beneficial.  Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in dermatology 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: Overturned

Nature of Statutory Criteria/Case Summary: A female enrollee has requested authorization and coverage for Xeljanz 10 mg, twice per day for treatment of the enrollees alopecia universalis. Findings:  The physician reviewer found that The submitted documentation supports the medical necessity of the requested medication regimen.  The patient has a history of alopecia universalis, with initial positive response to Xeljanz 5 mg, twice daily.  She is requesting coverage for the higher dosage of this medication, as her current dosage has lost its effectiveness.  Recent studies have identified a better success rate of hair regrowth using Xeljanz 10 mg, twice per day.  The Health Plan has previously approved the request for Xeljanz 5 mg, twice daily.  As there has been a loss of efficacy at the current lower dosage, it is medically appropriate to increase the dose to levels shown in the literature to be most effective in treating this condition.  All told, the requested Xeljanz 10 mg, twice per day is medically indicated for the treatment of this patient. Final Result: The reviewers 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: Physician reviewer number one is board certified in dermatology 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

This patient is a 26-year-old female with medically uncontrolled epilepsy.  There is a question of whether the onset of her seizures is focal or generalized.  The patient has had three grand mal seizures over approximately seven months. She partially responds to Depakote, but has significant side effects, especially morbid obesity with secondary polycystic ovarian syndrome and glucose intolerance. The patient has failed all other new and old anticonvulsant medications and has requested authorization for VNS therapy.  The Health Plan denied the request citing a lack of medical necessity.The patient has pharmaco-resistant epilepsy. She has been followed by a specialist in the treatment of epilepsy and has tried and failed all epilepsy therapies except Depakote, VNS therapy and epilepsy surgery. The patient has had a partial response to Depakote, but at the expense of serious side effects. Her parents also report episodes of eye flutter and confused speech on a near daily basis which may represent partial seizures. Due to the serious adverse effects of Depakote, the presence of persistent grand mal seizures, and the failure of multiple single and combination anti-epileptics, I find that VNS therapy is a reasonable and appropriate treatment modality. Therefore, I have determined the requested therapy is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a 15-year-old male enrollee requested authorization and coverage of inpatient infusion therapy for treatment of Laundau Kleifner Syndrome. The health plan denied the enrollees request indicating that inpatient infusion therapy 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 receiving infusions in an inpatient setting is not medically necessary, and that the health plans offer to continue providing the services through home health or in a physicians office are acceptable treatment settings for the patients needs.
Appeal type: Medical Necessity
Decision: Overturned

A 50-year-old male enrollee has requested magnetic resonance imaging (MRI) of the cervical spine, MRI of the thoracic spine and MRI of the lumbar spine for evaluation of his neck pain, thoracic pain and low back pain. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of a portion of the requested diagnostic procedures.  The patients cervical spine symptoms are chronic.  Although there are right-sided radicular symptoms, there are no red flags such as history of trauma, tumor or infection, and neurological examination is normal.  The lumbar spine process shows degenerative changes and no history of trauma, tumor or infection and no abnormal reflexes or other neurological abnormality.  Therefore, there are no red flags in the lumbar spine.  The records do not include electromyography providing support for radicular compromise within the cervical or lumbar spine.  However, evaluation of the thoracic spine indicated diffuse idiopathic skeletal hyperostosis versus ankylosing spondylitis.  The records support the medical necessity of the requested MRI of the thoracic spine, as there is 50 degree kyphosis and mention of compression fractures in the mid thoracic spine.  The requested MRI of the thoracic spine is indicated in order to clarify significant plain film findings of uncertain origin.  All told, the requested MRI of the thoracic spine is medically indicated.  However, the submitted documentation fails to demonstrate the medical necessity of the requested MRI of the cervical spine and MRI of the lumbar spine.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a nine-year-old male enrollee has requested growth hormone therapy for the treatment of his idiopathic growth hormone deficiency. Findings:  The physician reviewer found that The pituitary LH level was low, and testosterone level was high.  Lupron injections had been initiated. The patient has advanced bone age and likely premature epiphyseal closures. Growth in height had accelerated from four years of age according to the chart and was at the 90th percentile over recent years. The IGF-1 and IGFBP-3 levels preclude growth hormone deficiency. The differential diagnosis lies between testitoxicosis and idiopathic sexual precocity. There is a lack of literature support for growth hormone therapy in either case.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Simponi subcutaneous solution auto-injector 50 mg/0.5 mL. There is sufficient support for the requested medication in this clinical setting. There are multiple studies demonstrating the efficacy and safety of tumor necrosis factor inhibitors in treating moderate to severe rheumatoid arthritis. There is evidence that a second tumor necrosis factor inhibitor is effective for patients who have tried and failed a previous tumor necrosis factor inhibitor or have had adverse reactions to another tumor necrosis factor inhibitor. In this patients case, she has responded well to Simponi, a tumor necrosis factor inhibitor which is the preferred agent per the 2015 American College of Rheumatology guidelines. As such, Simponi subcutaneous solution auto-injector 50 mg/0.5 mL is medically necessary for the treatment of this patient. 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 rheumatology 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 13-year-old female enrollee has requested an interstitial glucose monitoring device (continuous blood sugar monitoring) for treatment of the enrollees Type 1 diabetes. Findings:  Three physician reviewers found that the American Diabetes Association (ADA) clinical practice guidelines for the treatment of diabetes mellitus recommend use of a continuous glucose monitor (CGM) in younger populations with adherence to ongoing use of the device in conjunction with intensive insulin regimens. The ADA also reports that CGM may be a supplemental tool in patients with hypoglycemia unawareness. This patient has recurring hypoglycemia and hyperglycemia. She has inadequate glycemic control as evidenced by her wide fluctuations of glucose with use of an insulin pump. She is at risk for hypoglycemic events due to her age, erratic eating schedule, and active lifestyle. The patient is expected to be compliant with the CGM, and it is therefore likely to be more beneficial than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned

A 28-year-old female enrollee requested authorization and coverage for a referral to an otolaryngologist for treatment of severe allergies.  The health plan has denied this request indicating that the requested referral is not medically necessary for treatment of the enrollees medical condition.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer overturned the health plans denial on the basis that the requested referral is medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for a knee magnetic resonance imaging (MRI). The submitted documentation does not support the medical necessity of the service at issue. The American College of Radiology (ACR) appropriateness criteria for chronic knee pain note an MRI may be indicated for non-traumatic knee pain when pain is persistent and radiographs are non-diagnostic. The guidelines further note an MRI is not indicated before completing a physical examination and radiography, or for the conditions of severe degenerative joint disease, inflammatory arthritis, stress fracture, osteonecrosis, or chronic regional pain syndrome. A study reports  the management of patients with knee pain is nonoperative both for degenerative meniscal tears and degenerative joint disease in its initial stages, and MRI studies add little value in the management of middle-aged and elderly patients with degenerative disease. The study further notes failure to respond to nonoperative measures warrants orthopedic assessment with radiographic studies and counseling on managing degenerative joint disease both nonoperatively and operatively. In this case, the patient was being treated for a medial meniscus root tear. The records reported knee pain with swelling and pain on ambulation and stair negotiation, and on examination, the knee was swollen and painful on mobilization. However, the submitted records did not include a recent knee x-ray or documentation of the trial and failure of conservative care measures. Therefore, the knee MRI was not medically necessary for the evaluation of this patient.Final Result: The reviewer determined the service at issue was 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 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: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee requested reimbursement for residential treatment services provided. The diagnoses include Major Depressive Disorder, Anxiety, Oppositional Defiant Disorder (ODD), and Obsessive Compulsive Disorder (OCD). The medical records reviewed indicated self-reports of improving mood; however, mental examination documented minimizing situations, tearfulness, and a safe discharge had not been in place. The APA Guidelines for major depressive disorder (MDD) notes the determination of an appropriate setting for treatment should include consideration of the patients symptom severity, co-occurring psychiatric or general medical conditions, available support system, and level of functioning. Determination of a treatment setting should also include consideration of the patients ability to adequately care for him- or herself, to provide reliable feedback to the psychiatrist, and to cooperate with treatment of the major depressive disorder. Measures such as hospitalization should be considered for patients who pose a serious threat of harm to themselves or others.In this case, the patients severity of illness and serious risk of self-harm is demonstrated by her severe depression. Regarding a support system, she has only limited support from a roommate and expressed concern about isolation at home. APA criteria for RTC level of care have been met. Therefore, the RTC services provided were medically necessary for this patient.Final Result: The reviewer determined that the requested services was 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

Nature of Statutory Criteria/Case Summary:   The parent of an enrollee has requested 40 hours per week direct intensive of applied behavioral analysis (ABA) for treatment of the enrollees medical condition.  Findings:  Two physician reviewers found that the documentation submitted for review indicates that the patient has behavioral issues that include elopement and self-injury in the school setting. There is research showing that behavioral health treatments including ABA are effective for addressing these behaviors. Thus, ABA services are clinically indicated. ABA is a prescribed set of skills that need to be taught in order to have functional communication and social interaction. These skills sets are broken down into smaller parts and then are taught at the lowest level needed for each patient. These skill sets are designed to remediate the core problems of the autism spectrum disorders. In this case, the patient needs ABA services in the school setting to address behaviors specifically self-injury, elopement and safety issues. However, the requested additional 20 hours of ABA services are not indicated. In this case, an additional seven hours of ABA services rendered in the school setting is clinically indicated. As such, 27 hours per week direct intensive of ABA is medically necessary for treatment of the patients autism.  Final Result: Two reviewers 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: One reviewer is board certified in child neurology and is actively practicing. One reviewer is board certified in pediatrics and child neurology and is actively practicing. One reviewer is board certified in pediatrics with sub-specialty certification in developmental-behavioral pediatrics and is 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: Experimental/Investigational
Decision: Overturned

The parent of a nine-year-old female enrollee has requested  for biofeedback training for treatment of the enrollees abdominal pain. Findings:  Three physician reviewers found that this patient has recurrent abdominal pain. She has had headaches and has been diagnosed with cyclic vomiting syndrome in the past. These are findings suggestive of abdominal migraine. Biofeedback is an accepted modality for treatment of migraines, its use in patients with abdominal migraine is medically appropriate.
Appeal type: Experimental/Investigational
Decision: Upheld

The parent of a one-year-old male enrollee has requested a bone-anchored hearing aid for treatment of the enrollees moderate to severe mixed hearing loss. Findings:  Three physician reviewers found that there are a limited number of scientific studies regarding bone-anchored hearing aid implantation in children younger than five years of age. Most studies regarding the use of this device in children involved an older age group. Although the outcomes were generally positive and not with greater than expected complication rates for the procedure, there have been limited studies involving children less than five years of age. More outcome data is needed to determine if implantation at such a young age is safe.
Appeal type: Medical Necessity
Decision: Overturned

A 36-year-old female enrollee has requested residential treatment for treatment of her eating disorder. Findings:  The physician reviewer found that review of the literature including the American Psychiatric Association Practice Guidelines indicates that residential treatment level of care is medically necessary and indicated for patients who are less than 85% of their ideal body weight. After her RTC admission, the patient was continuing to gain weight. While there is no indication of acute physiological compromise, the patient was not appropriate for discharge on the said date as this would have put her at significant risk and would have been inconsistent with current practice standards. The patient is showing significant progress in treatment and it is reasonable to expect that with continued residential treatment, she will continue to gain weight. Thus, continued residential services were and are medically necessary from the date in question onward.
Appeal type: Experimental/Investigational
Decision: Upheld

A 57-year-old female enrollee has requested a PET scan for an evaluation of her cognitive and psychomotor slowing. Findings:  Three physician reviewers found that there are no adequate standards by which to judge PET scan results in the differential diagnosis of cognitive impairment, as noted in the study by Matsuda. Furthermore, there are no therapeutic implications in this particular case which would be addressed by PET scanning as noted by Jagust and colleagues. In the absence of any evidence of clinical value in this setting, the proposed PET scan is not indicated.