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

A 66-year-old female enrollee has requested emergent psychiatric care followed by acute inpatient level of care for treatment of her medical condition. Findings:  The physician reviewer found that the services rendered during the initial treatment period were not required at the emergent level of care and the services rendered during the second treatment period were not medically necessary at the acute inpatient level of care. American Psychiatric Association (APA) practice guidelines indicate that patients should be managed in the least restrictive setting that is likely to be safe and effective. Based on the documentation provided, the patients condition had stabilized by initial treatment date and she was no longer experiencing a psychiatric emergency. The submitted records include no evidence of acute risk to self or others as of that date and no indication of a need for restraints, seclusion or intra-muscular medications. Additionally, the patient was cooperative with treatment. Thus, the patient did not require treatment at an emergent level of care during her initial treatment period. Furthermore, as of the start date of the second treatment period, the continued need for containment and skilled observation and procedures on a 24-hour basis is not established in the medical record documentation provided. There was no evidence of risk of harm to self or others and the patient was cooperating with treatment. The patient did not require the intensity of service that is associated with acute inpatient services during the second treatment period. During this period, the patient was appropriate for treatment in a partial hospitalization program (PHP), which is the clinically indicated level of care in this setting. Per APA guidelines, partial hospitalization is appropriate for patients who do not require 24-hour protected, controlled or monitored environment and for whom there is evidence of capacity for reliable attendance at the PHP and compliance with a medication regime. As of the start date of the second treatment period, the patient was no longer at acute risk of harm to self or others and was cooperative with treatment. Thus, a PHP level of care would have been appropriate during this treatment period.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for the medication Dupixent. Dupixent is a medication that is FDA approved for treatment of moderate and severe atopic dermatitis in patients age six and over. Dupixent (dupilumab) may be a good alternative for those with moderate to severe atopic dermatitis with an acceptable safety profile, which was also reiterated in a phase 3 randomized controlled trial. In this case, the patient has been dealing with atopic dermatitis since early childhood. The patient is noted to have flares, with the most recent and severe flare being one that the patient sought care for this year. The patient has been treated with topical steroids, topical antibiotics and anti-histamines. Other systemic therapies such as phototherapy and other immunosuppressants have been recommended. The schedule for phototherapy, however, is not feasible for a school-aged child, and immunosuppressants have sides effects to be considered. Under these circumstances, the favorable safety profile of Dupixent must be taken into consideration. Accordingly, the requested medication Dupixent is medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested medication is medically necessary to treat the patient's medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The 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 a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for transcranial magnetic stimulation (TMS). While TMS is efficacious and well tolerated in adults with MDD, the potential utility of TMS in adolescents with treatment-resistant depression is based on case reports and unblinded studies with a relatively small sample size of patients. Medical literatures report that while preliminary data suggest that repetitive TMS (rTMS) may be efficacious for pediatric depression, randomized controlled trials that examine both short and long-term outcomes are needed before definitively recommending rTMS for adolescents with refractory depression. Researchers report that while a single center, open trial suggests that rTMS is a safe and effective treatment for youth with treatment-resistant major depressive disorder, larger randomized controlled trials are needed. Researchers note that systematic data on the safety of TMS in children and adolescents are lacking, and that at present, there are many unknowns regarding the optimal stimulation parameters and potential biomarkers for depressed adolescents receiving TMS. They also indicated that consideration should be taken regarding the neurodevelopment and unknowns associated with TMS exposure in adolescents. In a multicenter, double-blinded, randomized sham-controlled trial of TMS for treatment-resistant depression in adolescents, researchers found no statistically significant differences in clinical outcomes between the active TMS and sham TMS groups. The authors also note that evidence on the efficacy of rTMS in adolescent depression is scanty, with many limitations, and that while the safety profile of rTMS for adolescent depression appears to be desirable, many parameters, including the most favorable approaches, have yet to be determined. Studies of TMS in the treatment of adolescent psychiatric disorders is largely focused on depression and relatively limited. Given that the efficacy of TMS for the treatment of depression and other psychiatric conditions in adolescents has not yet been established, the requested services are not medically indicated. In this patients case, TMS is not in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, the requested services are not clinically appropriate in terms of type, frequency, extent, site, and duration. Therefore, TMS (36 sessions) is not medically necessary for the treatment of this patient.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 psychiatry with sub-specialty certification in child and adolescent psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for 82.3 hours per month of direct 1:1 applied behavioral analysis (ABA) services (Code 97153) and 1.17 hours per month of report writing (Code 90889). According to the authors, the definition entails healthcare services that a provider, exercising a prudent clinical judgment, would provide to a patient for the purpose of evaluating, diagnosing, or treating an illness, injury, disease, or its symptoms and are (a) required to meet the essential health needs of the patient; (b) consistent with the diagnosis of the condition for which they are required; (c) consistent in type, frequency, and duration of treatment with scientifically based guidelines as determined by medical research; (d) required for purposes other than the convenience of the provider or the comfort of the patient; and (e) rendered in the least intensive setting that is appropriate for the delivery of health care. While this patient meets the medical necessity criteria for the Health Plans authorized 47.7 hours of 1:1 ABA per month, she does not meet medical necessity criteria for the additional 82.3 hours per month based on subsection (d). As the increase in ABA is only for a short duration, this suggests that the level of medically provided ABA is not medically necessary. The Behavior Analyst Certification Board (BACB) reports that when determining treatment intensity, the time the client spends in activities such as school and other therapies should not be counted in or deducted from the recommended number of hours of ABA treatment. As the intensity is adjusted to account for school or other activities, it is not medically required at all times. Therefore, the requested 82.3 hours per month of direct 1:1 ABA services (Code 97153) and 1.17 hours per month of report writing (Code 90889) are not medically necessary for treatment of this patient. 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 a licensed B.C.B.A, board certified in psychology, 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 enrollees parent is requesting reimbursement and authorization and coverage for psychiatric intensive outpatient program (IOP) services. The enrollees admission diagnoses were disruptive mood dysregulation disorder, unspecified anxiety disorder, cannabis use disorder, severe; and to rule out attention deficit, hyperactivity disorder; predominately inattentive presentation.  Previous treatment includes individual therapy, residential therapy, and medication management. His treatment plan on admission focused on stabilizing his mood by decreasing depressive symptoms from several times daily to a few times weekly. Other objectives included abstinence from drinking alcohol and using other substances, as well as cutting or other self-harm behaviors; decreasing severe anxiety symptoms from several times daily to a few times weekly. The enrollees treating physician believes he should show a 60-70% reduction in the frequency of unstable mood, explosive episodes, and highly irritable mood.  He currently exhibits difficulty with these symptoms about 80-90% of the time. The enrollee exhibits significant difficulty modulating unstable mood, anxiety, and impulsivity problems.  He struggles with destructive and impulsive behaviors. The enrollee continues to struggle using constructive ways of communicating his frustration with others, low frustration tolerance, drug-seeking behaviors and overall poor judgment. CALOCUS scores were utilized in this case to assess appropriate level of care. For risk of harm, the enrollees score is 3, due to substance use. For functional status, the enrollees score is 4, as he had been asked to leave school, and had been truant. For comorbidity, the enrollees score is 3, due to disruptive mood disorder, anxiety, cannabis use, and rule-out attention deficit hyperactivity disorder (ADHD). For recovery environment level of stress, the enrollees score is 4, due to substance use and conflicts with his father. The physician reviewer found that  recovery environment level of support, the enrollees score is 3, due his parents being inconsistent with consequences. For treatment and recovery history, the enrollees score is 4, due to due to multiple previous failed attempts of treatment. For engagement and recovery status, the enrollees score is 4, due to the childs difficulty committing to treatment; such as vaping while he was in the program. The enrollees composite CALOCUS score is 25, which correlates with Intensive Outpatient Program. The enrollee was being considered for residential treatment, so stepping down to a lower level of care would not be appropriate.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a six-year-old male with a history of febrile seizures. The patient also has developmental and social delays and has been diagnosed with expressive language delay, oral motor difficulties, mild phonological disorder, and moderate developmental apraxia of speech. The patient underwent a developmental evaluation in 2002, which reflected multiple components of developmental delay with both sensory issues and fine and gross motor issues. The patient had many of the components of pervasive developmental disorder, but did not meet the criteria for pervasive developmental disorder. Subsequently, the patient was diagnosed with the above language disorder by his speech therapist. It appears the patient has received approximately eight months of speech therapy. A request has been made for additional speech therapy. The Health Plan has denied authorization for additional speech therapy on the basis that it is not medically necessary. In light of the evaluation by the patients developmental psychologist, which reveals a spectrum of delays it is unlikely the patients speech issues are related to his seizures (especially febrile seizures). The available clinical evidence seems to indicate the patient has a speech delay that is developmental in nature. Therapies for developmental delays are not medically necessary and are typically appropriately provided through means other than individual therapy. As such, the submitted evidence provides no medical indication for speech therapy at this time. Therefore, I have determined that the requested therapy is not medically necessary for the treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Urgent Care
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for inpatient hospitalization services.   Findings:  The physician reviewer found that the inpatient hospitalization services provided was necessary for treatment of an emergency medical condition. The patient was diagnosed with active labor on her presentation to the local out-of-network hospital. Labor progresses a variable rates and transfer from one hospital to another in the active phase of labor is not advised. On average, iparous women progress from 4 to 10 cm in 5.5 hours, indicating that many women will progress more rapidly than this. Given that the second stage of labor, which includes pushing, typically takes two to three hours, this patient had progressed more rapidly. In addition, epidural analgesia, which this patient received, has been associated with slower progress in labor. Had this patient been transferred to another hospital, she would not have received the epidural analgesia and may have delivered sooner. In addition to the risk of delivery en route, fetal monitoring is required in labor and this cannot be accomplished during transport. For the reasons provided, transfer once active labor has been diagnosed is not recommended unless the initial hospital does not have obstetric facilities. Since the hospital was capable of providing the necessary care, transfer was contraindicated. Accordingly, the services at issue were necessary for treatment of an emergency medical condition. Thus, the patient received emergency medical services on the dates of service at issue. Final Result: The reviewer determined that the patient received emergency medical services on the dates of service at issue. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in obstetrics and gynecology with sub-specialty certification in maternal and fetal 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 has requested authorization and coverage for Nuedexta capsules (dextromethorphan HBr-quinidine sulfate 20-10 mg). The patient has been diagnosed with pseudobulbar affect (PBA). Researchers reported that PBA is characterized by uncontrolled crying or laughing which may be disproportionate or inappropriate to the social context. There is a disparity between the patients emotional expression and his or her emotional experience. The authors also reported, that the goal of treatment of PBA is to diminish the severity and frequency of episodes. The targets of treatment are primarily norepinephrine, serotonin, or glutamate, using tricyclic antidepressants (TCAs), selective serotonin reductase inhibitors (SSRIs), and, most recently, the cough suppressant dextromethorphan. Medical literature states that dextromethorphan/quinidine is indicated for the treatment of PBA and has shown efficacy in patients with underlying ALS and MS. There is insufficient evidence for the use of Nuedexta in the treatment of PBA associated with TBI. In this case, the patient has been diagnosed with PBA secondary to TBI. The record does not clearly document the patient has had benefit with Nuedexta. The medical evidence does not support the requested medication in this clinical setting. Therefore, Nuedexta capsules (dextromethorphan HBr-quinidine sulfate 20-10 mg) is not medically necessary for the 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 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for platelet rich plasma (PRP) treatment (CPT 0232T). Findings:  The physician reviewer found that This patient is being treated for osteoarthritis of the left ankle. The patient previously underwent left ankle arthrodesis peroneus longus and brevis tenolysis in 2019 with hardware removal in 2021. The patient presents with continued complaints of foot pain that is persistent and noted to be in the heel rated at 4/10 in the posterior aspect. The provider noted that the patient has been treated with physical therapy. The provider has recommended treatment with PRP injections. On review of the peer-reviewed medical literature, the data on PRP injections remains mixed with regard to efficacy in the treatment of patients with ankle arthritis. Fukawa and colleagues concluded that intra-articular PRP injections resulted in no serious adverse effects, while it reduced pain in the patients with ankle osteoarthritis. Paget and colleagues concluded among patients with ankle osteoarthritis, intra-articular PRP injections, compared with placebo injections, did not significantly improve ankle symptoms and function over 26 weeks. However, there is a paucity of large-scale, peer-reviewed literature demonstrating the long-term safety and efficacy of PRP injection in the treatment of patients with ankle osteoarthritis. For these reasons, the requested PRP treatment (CPT 0232T) is not likely to be more beneficial for treatment of the patients condition than any available standard therapy.Findings:  Three of the three physician reviewers found the requested PRP treatment (CPT 0232T) is not likely to be more beneficial for treatment of the patients condition than any available standard therapy.Final Result: The reviewers determined that the requested services are 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: Physician reviewer 1 is board certified in orthopedic surgery and is actively practicing. Physician reviewer 2 is board certified in orthopedic surgery and is actively practicing. Physician reviewer 3 is board certified in orthopedic surgery and is actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 28-year-old female enrollee has requested acute inpatient psychiatric treatment for the treatment of her major depressive disorder. Findings:  The physician reviewer found that psychiatric inpatient hospitalization was not medically necessary for this patient. She did not pose imminent risk to herself or others. She was not manic, psychotic or aggressive. There was no evidence of intoxication or withdrawal. She was not gravely disabled. Thus, based on American Psychiatric Association guidelines, the patient no longer required an acute inpatient level of care as of the last authorized date of service. She could have been treated safely and effectively in a less intensive treatment setting such as partial hospitalization.
Appeal type: Medical Necessity
Decision: Overturned

A 59-year-old female enrollee has requested for Provigil for treatment of her shift-work sleep disorder.    Findings:  The physician reviewer found that shift-work sleep disorder is a well-known indication for treatment with Provigil
Appeal type: Medical Necessity
Decision: Overturned

A 48-year-old female enrollee requested authorization and coverage of surgical excision of a lump in the enrollee's right eyelid.  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 surgery is medically necessary for treatment of the patients medical condition.