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

Nature of Statutory Criteria/Case Summary: The patient was diagnosed with alcohol dependence and generalized anxiety disorder. The patient was initially treated in a detoxification program for 10 days for severe alcohol use. The patient was noted to drink 16 ounces of vodka daily and was admitted to an intensive outpatient program (IOP). The patient was reported to be attentive and engaged in group therapy. The records noted alcohol dependence and generalized anxiety disorder. She denied suicidal ideation and reported feeling better due to talking about her problems. The patient endorsed social isolation and substance use as behaviors that interfere with her quality of life. She also reported a stress dream about drinking. The patient was noted to be attentive, engaged, and more hopeful. The patient has requested reimbursement for intensive outpatient program (IOP) services. The Health Plan denied the request and reported the services at issue were not medically necessary for the treatment of this patient. The issue in this case is whether intensive outpatient program (IOP) services were medically necessary for the treatment of the patients medical condition. For acute intoxication and/or withdrawal potential, the patient was at minimal risk of severe withdrawal due to the recent completion of a detoxification program. For biomedical conditions/complications, the patient did not have medical conditions or complications. For emotional/behavioral/cognitive conditions/complications, the patient was diagnosed with generalized anxiety disorder. For readiness to change, the patient had variable treatment engagement and required a structured program, as she had previously been unable to engage in treatment for years. For relapse/continued use/continued problem potential, the patient had a high likelihood for relapse without close monitoring and support. For recovery environment, the patient had an unsupportive environment as her family did not participate in her treatment. In this case, the patients relapse and safety risk factors include her tendency to isolate and comorbid anxiety. An IOP treatment, which encompasses services that are capable of meeting the complex needs of patients with addiction and co-occurring conditions, such as her anxiety disorder. The patient was reported to be engaged in treatment with gains including reduced anxiety and more hope. The medical evidence supports the services received in this clinical setting. Therefore, intensive outpatient program (IOP) services were medically necessary for the treatment of 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 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 72-year-old female enrollee has requested for acute rehabilitation services for treatment of the enrollee following a cerebral vascular accident. Findings:  The physician reviewer found that there was no indication for transfer to acute rehabilitation as the patient was making steady progress, as expected, at the SNF level of care. Transfer from SNF rehabilitation to acute rehabilitation in this setting is not consistent with current national standards because there is no expectation of clinical benefit.
Appeal type: Medical Necessity
Decision: Upheld

A 56-year-old male enrollee has requested Zetia (10mg) for the treatment of his high cholesterol. Findings:  The physician reviewer found that the National Cholesterol Education Program (NCEP) Expert Panel recommends an LDL level less than 100 mg/dl for those patients with coronary artery disease. It was proposed that that the goal LDL level be reduced to less than 70 mg/dl for very high risk patients, but this patient does not fall into this category (Grundy and colleagues). Therefore, for this patient, his LDL level should be less than 100 mg/dl. There have been multiple clinical trials showing a decrease in the risk of coronary heart disease and all-cause mortality when statins are used to treated hyperlipidemia (LaRosa and colleagues) and they are the only class of drugs to have demonstrated a reduction in overall mortality. Therefore, statins are the first choice for treatment in patients with hyperlipidemia. If LDL cannot be reduced to the goal level with the use of statin therapy alone, then the addition of another agent (such as Zetia) is considered. As the Health Plan indicates, the submitted evidence does not demonstrate that this patient has had an adequate documented trial of the statin Lipitor 80mg to reduce his LDL to less than 100 mg/dl.  This should be the first-line treatment. If his LDL level were to remain above 100 mg/dl after an adequate trial of Lipitor 80mg, then Zetia should be considered.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for mental health services for treatment of his behavioral health conditions. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  This patient was struggling with behavioral outbursts prior to his admission.  The medical records do not support active suicidal ideation or psychosis during the several weeks after the patient was admitted.  The records indicate the patient was open in his individual and group therapy sessions throughout his stay.  He was not displaying any significant or severe behavioral problems after his admission.  Per the records, he needed additional treatment to further improve his social functioning, mood, anxiety, family relationships, and behavioral issues. However, it appears that he did not need the restrictiveness of a residential psychiatric treatment facility in order to receive his care.  Residential treatment is used for acute stabilization of psychiatric conditions. It is not evidenced-based for long-term type treatment.  Outpatient treatment and least restrictive options are considered first lines of care.  There are benefits to in-home therapy due to the involvement with family as well as generalization of learned skills in a natural setting.  In this patients case, he could have been treated in a less restrictive setting safely and effectively.  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 a 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: Experimental/Investigational
Decision: Upheld

An 18-year-old male has requested transcranial magnetic stimulation (TMS) therapy for treatment of depression with suicidal ideation.  Findings:  Two physician reviewers found that the patient presents with a four year history of depression. The records indicate that his most recent psychiatric diagnoses are major depressive disorder and social anxiety disorder. The patients symptom complex consists of depressed mood with episodic suicidal ideation and self-injurious behavior, anhedonia, difficulty concentrating, poor motivation, and increased appetite. In terms of past psychiatric treatments, the patient had been active in dialectical behavior therapy (DBT) and seen by a psychiatrist and a therapist in the outpatient setting. He also had three psychiatric admissions and treatment at the partial hospital level of care. The patient has trialed multiple psychotropic medications including fluoxetine, bupropion, venlafaxine, mirtazapine, lamotrigine, aripiprazole, stimulants, benzodiazepines, and thyroid hormone. Psychopharmacotherapy has not achieved remission. Due to persistent affective symptoms, transcranial magnetic stimulation (TMS) therapy was recommended. Although this fairly new treatment technology lacks a robust evidence base at this stage of implementation, the literature supporting TMS in terms of volume, quality, and range of investigation continues to grow. Schutter and Gross suggest that the efficacy of TMS may be greater than originally reported, while George and Demitrack provided more conclusive findings in well-developed studies. In addition, the FDA approved TMS in 2008 based on the available data and the American Psychiatric Association (APA) endorses TMS for the acute phase treatment of major depressive disorder. The patients records provided for review do not document previous attempts at psychotherapy, such as interpersonal therapy or cognitive behavioral therapy, which are proven effective in the treatment of depression. Further, the patient has been treated with multiple medications, but he has not exhausted augmentative strategies, or trialed antidepressants from alternative classes, such as the tricyclic antidepressants and monoamine oxidase inhibitors, which have a proven track record in the treatment of depression. Finally, there is no consideration given to electroconvulsive therapy, which remains the proven non-pharmacologic intervention to which other stimulatory techniques are measured.
Appeal type: Medical Necessity
Decision: Upheld

A 59-year-old male enrollee has requested chiropractic treatment for the treatment of his neck pain. Findings:  The physician reviewer found that this patient has a chronic condition, per the documentation submitted. There is no documentation of any functional gains. Additionally, there are no specifics as to the objective restoration of lost function or degree of range of motion improvements. There is no documentation at follow-up visits as to the previous orthopedic, neurological or motion analysis. The submitted records do not include documentation pertaining to patient home care with rehabilitation as would be expected in light of such a chronic condition. There is a lack of specific documentation from the previous treatments. There is no documentation as to postural analysis and no review of chief complaint as related to the previous visit. There is no documentation as to palliative and/or provocative complaints. There is a lack of progression of treatment effectiveness for all the previous visits in light of the complaint appearing to be for the same area of the body. Based upon the documentation provided, chiropractic treatment provided was not and is not clinically indicated.
Appeal type: Medical Necessity
Decision: Overturned

A male enrollee requested Harvoni 90 mg/400 mg tablets for 12 weeks for medical treatment of his chronic hepatitis C virus genotype 1a.  Findings:  Two physician reviewers found that the most recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C, regardless of fibrosis, should be treated except those with limited life expectancy (less than 12 months) due to non-liver-related comorbid conditions. Based on the provided records, published evidence of safety and efficacy in the published literature and clinical guidelines, the requested 12 week course of Harvoni should be approved as medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for hip surgery arthroscopy hip with femoroplasty and arthroscopy hip with labral repair. Findings:  The physician reviewer found that Hip arthroscopy appears to be a safe and efficacious treatment for labral tears and femoroacetabular impingement (FAI) in older patients who do not have significant underlying degenerative changes. However, in this population, there is a significant proportion of patients who eventually require hip arthroplasty. Outcomes may be affected by type of treatment (i.e. labral debridement versus repair). Additional high-quality studies are needed to understand how these factors affect outcomes. Khan and colleagues report, Arthroscopic intervention results in improvements in functional outcomes at both the short-term and midterm for patients with symptomatic FAI in the absence of significant existing degenerative changes. Labral repair may result in improvements over labral debridement. In this case, the patient has a left hip labrum tear and history of bilateral hip pain and coccydynia. The patient reports persistent pain despite participation in physical therapy and home exercise. An examination of the left hip showed a painful range of motion with a hip extension of zero degrees, flexion of 100 degrees, internal rotation of ten degrees, external rotation of 45 degrees, hip strength at five out of five, and a positive FABIR test. While the provider noted FAI, this was not supported by imaging studies. Therefore, hip arthroscopy with labral repair (CPT 29916) is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested services are partially medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned.Credentials/Qualifications: The reviewer is board certified in 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for special blood testing (advanced lipoprotein testing). Findings:  Two of the three physician reviewers found that guidelines for the management of cardiac risk and dyslipidemia have been established, are periodically updated by expert committees and are endorsed by several national organizations. These guidelines currently do not recommend routine performance of specialized tests in the context of assessing coronary risk, including lipoprotein-associated phospholipase A2 (Lp-PLA2), sub-classifications of low-density lipoprotein (LDL), high-density lipoprotein (HDL) subclasses, lipoprotein (a), C-reactive protein, high sensitivity C-reactive protein, insulin, fibrinogen, genetic testing and homocysteine. Treatment change or addition 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. Although results of some of these specialized tests may be abnormal and considered independent risk markers for coronary disease, there is a lack of controlled trials that demonstrate outcome benefits by treating routinely obtained abnormal results. Thus, special blood testing (advanced lipoprotein testing) was not likely to have been superior over other available methods of evaluating this patient. Final Result: The reviewers determined 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 sub-specialty 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The enrollee has requested reimbursement for the Afirma Gene Expression Classifier (GEC) molecular test for evaluation of the enrollees thyroid nodule. Findings:  Two of the physician reviewers found that While a FNA biopsy of a suspicious thyroid nodule is typically an accurate means of assessing whether the nodule is benign or malignant, approximately 15% of FNA biopsy results are considered to be indeterminate (Alexander, et al). Until recently, the only way to establish whether the nodule was in fact thyroid cancer was via surgical excision even though the majority turn out to be benign. Afirma utilizes a GEC in order to help determine the likelihood of malignancy of nodules with indeterminate cytology on FNA biopsy, thereby decreasing the need for unnecessary surgeries. All told, the Afirma GEC molecular test provided on 11/29/16 was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: The reviewers determined that the testing at issue was 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: Physician reviewer number one is board certified in internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.Physician reviewer number two is board certified in internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.Physician reviewer number three is board certified in internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The mother of a 14-year-old male enrollee  requested authorization and coverage of liposuction for the treatment of the enrollee's gynecomastia.  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 overturned the health plans denial on the basis that the requested procedure is medically necessary for the treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for Molift RgoSling HighBack net sling and/or Molift RgoSling ambulating vest with groin/pelvic straps for use with an authorized Molift Smart 150 electric Hoyer lift. Caregiving for children with cerebral palsy may contribute directly to both the psychological and the physical health of the caregivers, with practical day-to-day needs of the child creating challenges for parents. Darragh and colleagues note that caregivers for individuals with chronic physical disability reported high levels of physical strain and musculoskeletal discomfort, and identified several activities related to mobility and self-care as the most physically demanding. In investigating the effects of passive versus dynamic loading interventions on bone health in nonambulatory children, Damcott and colleagues report that increases in bone mineral density (BMD) were observed during dynamic standing, whereas passive standing appeared to maintain the baseline BMD. The authors further reported that increases in bone mineral content were observed in each standing intervention, with dynamic standing inducing greater increases. In this case, the patient has quadriplegic cerebral palsy, and requires moderate-to-complete assistance for transfers. The patient weighs 72 pounds, and his mother, described as slightly built, has already sustained injury in her wrists and pain in her back due to caring for the patients transfers.  In this case, a net sling is medically indicated to safely connect the patient to the Hoyer lift so that he may be transferred, and an ambulating vest with groin/pelvic straps will permit the patient to weight-bear on standing, and to use a treadmill to maintain bone health. Without these essential adjuncts to the Hoyer lift, the requested device is an unusable piece of equipment. Given that the requested equipment with allow the patient to stand and use a treadmill, which may also decrease the risk of osteoporosis, which is common in children with cerebral palsy, the requested equipment is medically indicated. Therefore, Molift RgoSling HighBack net sling and/or Molift RgoSling ambulating vest with groin/pelvic straps for use with an authorized Molift Smart 150 electric Hoyer lift is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested equipment 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 neurology with special qualification in child neurology with sub-specialty certification in neurodevelopmental disabilities 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

The parents of a six-year-old male enrollee have requested applied behavioral analysis (ABA) services for the treatment of the enrollees autism. Findings:  The physician reviewer found that this patient has multiple behavior issues including non-compliance, tantrums, and visual stereotyping as well as other maladaptive behaviors. The scientific data suggests that these behaviors respond well to ABA programs that are intensive, structured, and individualized with explicit teaching of social skills, communication and learning to learn skills. The progress reports indicate that he has already made significant gains in his behavior and no longer displays maladaptive behavior and his stereotyping has decreased. For this reason, the ABA services provided were medically indicated and necessary during the period at issue. As this patient is likely to continue to benefit from ABA therapy, it has been shown to be medically necessary in the continuation of his care and should be approved.