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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for iontophoresis. This patient presents with palmar, plantar, and axillary hyperhidrosis that has only partially improved with Drysol, oxybutynin, and topical antiperspirants. The provider recommended treatment with iontophoresis. There are data from clinical trials reporting that iontophoresis can be successful in alleviating the symptoms of palmar or plantar hyperhidrosis in approximately 85% of patients treated. Iontophoresis is specifically indicated for the palms and soles of the feet, but there is a lack of data demonstrating similar efficacy in the axillae. Currently, iontophoresis is considered a first-line therapy for this patients palmar and plantar hyperhidrosis over the remaining alternative, Botox, given the pain associated with Botox injections at these sites. In summary, iontophoresis to the palms and feet soles is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy, while iontophoresis to the armpits is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings:  All three physician reviewers found a portion of the requested services is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined a portion of the requested services is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be partially overturned. Specifically, all three medical experts decided that iontophoresis to the palms and feet soles is likely to be more beneficial for you than any available standard therapy, while iontophoresis to the armpits is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Credentials/Qualifications: Physician reviewers 1, 2, and 3 are board certified in dermatology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:   An enrollee has requested excision of benign skin lesion with reconstruction of left lower lid procedure for treatment of her medical condition. Findings: The physician reviewer found that the excision of benign skin lesion with reconstruction of left lower lid procedure was not medically necessary for treatment of the patients medical condition. The medical records submitted for review fail to document a medical and functional indication for eyelid surgery. The clinical note states lid redundant fold as the indication for surgery. However, this descriptor does not refer to a pathologic process. All told, the excision of benign skin lesion with reconstruction of left lower lid procedure was not medically necessary for treatment of the patients medical condition.  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 ophthalmology with sub-specialty certification in ocuplastic 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 63-year-old male has requested cardiac computed tomography angiography (CTA) with contrast and calcium score without contrast for evaluation of his hypertension, diabetes mellitus, and shortness of breath.   Findings:  Two physician reviewers found that the patient has a history of diabetes, hypertension, obesity, hypothyroidism, prostatitis, dyslipidemia and obstructive sleep apnea. A clinic note documents dyspnea, a normal cardiovascular physical examination and a normal electrocardiogram. An echocardiogram  revealed normal left ventricular systolic function with an ejection fraction of 0.55 to 0.60, with moderate atrial enlargement. An exercise nuclear stress test revealed no provokable ischemia with a left ventricular ejection fraction of 0.47. Based on the records provided, the patient presents with increased coronary risk and symptoms of dyspnea. The patient has a normal cardiovascular physical examination, normal electrocardiogram, normal ventricular systolic function on echocardiography, and no provokable ischemia on nuclear stress testing. In this circumstance of an unequivocally negative nuclear stress test in a patient without chest discomfort or other abnormality suggestive of coronary ischemia additional evaluation with coronary CT angiography is not considered standard accepted practice in the medical community. Current guidelines that are endorsed by several national organizations also do not consider coronary CT angiography appropriate in patients with an unequivocally negative nuclear stress test (Miller, et al). Additionally, if an assessment of coronary anatomy were thought to be necessary to assess for coronary stenosis, even with a negative stress test, then conventional coronary angiography is preferred given its improved accuracy compared to coronary CT angiography and the ability to intervene using percutaneous revascularization during the same procedure, if needed (Mark, et al).
Appeal type: Experimental/Investigational
Decision: Upheld

A 56-year-old male has requested coverage for past computed tomography angiography (CTA) of the heart for evaluation of his coronary heart disease.  Findings:  Two physician reviewers found that the patient has a history of HIV infection, dyslipidemia and coronary artery disease.  He underwent coronary stenting to the left anterior descending coronary artery six years ago after presenting with chest discomfort. Follow up coronary CT scanning two years later was reported to show 50% stenosis in the left anterior descending coronary artery with ostial stenosis and ulcerative plaque in the left circumflex treated medically. A repeat coronary computed tomography angiography (CT angiography) was performed two years later with a documented indication of coronary artery disease and stents.  There is also reference to chest discomfort.  In this circumstance of known coronary artery disease and prior coronary stenting, coronary CT angiography is not considered an accepted practice in the medical community. Coronary stents often create artifacts on coronary CT angiography that preclude an accurate assessment of potential in-stent stenosis. In addition, coronary calcium is more common in patients with coronary stenosis and the presence of significant calcium can also impair accuracy in quantification of coronary stenosis. If assessment of coronary artery stenosis is thought to be necessary then invasive coronary angiography is preferred, due to its improved accuracy relative to coronary CT angiography (Miller, et al.) and the ability to intervene with coronary revascularization during the same procedure, if clinically indicated. Current guidelines that are endorsed by several national organizations do not consider coronary CT angiography appropriate in patients with known coronary artery disease and prior coronary stenting (Mark, et al.)
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential treatment center services provided. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  The Level of Care Utilization System (LOCUS) is commonly used to determine appropriate levels of care.  Applying LOCUS, the patient presented with a moderate risk of harm, scored as 3. She had no prior history of any suicide attempts. She denied suicidal ideation. However, the patient had a history of excessive alcohol use resulting in harmful behaviors. In terms of functional status, her score was 3. The patient had moderate impairment. She had a tumultuous relationship with her husband. The records document moderate comorbidity, which scored as 3. The patient had a diagnosis of alcohol use disorder and continued to drink despite negative consequences. She also had anxiety and depression as psychiatric comorbidities.  The records noted a moderately stressful environment, scored as 3. The patient had discord in her current marriage, and there was access to alcohol.  Regarding the patients support, the records indicate a score of 2.  The patient had support from her children, extended family, and sober friends. In terms of treatment history, her score was 2. She previously displayed significant response to treatment and recovery management. The patient was able to maintain sobriety for a four mouth period.  In terms of engagement, the records indicate a score of 2. Per the records, the patient was engaged in her recovery. She was participating in group sessions. Based on the records, the patients total score was 18. Thus, partial hospitalization program or an intensive outpatient program level of care would have been appropriate.  The medical evidence does not support residential treatment level of care in this clinical setting.  All told, residential treatment center services provided were not medically necessary for the treatment of this patient. Final Result: The reviewers 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: Physician reviewer is board certified in psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested Forteo for treatment of her osteoporosis.   The physician reviewer found that the current medical evidence supports the medication at issue in this clinical setting.  Osteoporosis is an increasingly widespread condition, and fractures are the most dangerous aspect of osteoporosis.  Fractures can lead to acute and chronic pain as well as increased mortality.  Until recently, pharmacological options for the treatment of osteoporosis have been limited to antiresorptive agents, including the oral bisphosphonates.  Newer treatment agents have become available over the past few years, including Forteo.  Forteo is a recombinant form of the biologically active component of parathyroid hormone which has been shown to increase bone mass and prevent fractures in osteoporotic bones.  Recent data also demonstrates that Forteo may aid in the healing of fractures and non-unions in osteoporotic patients.  Forteo is indicated for the treatment of postmenopausal women with osteoporosis at high risk for fracture, defined as a history of osteoporotic fracture, multiple risk factors for fracture, or patients who have failed or are intolerant to other available osteoporosis therapy.  Because this patient has sustained multiple fractures while on bisphosphonate therapy, Forteo was medically indicated for the treatment of this patient. Final Result: The reviewer determined that the medication at issue 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 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

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement and authorization and coverage for intensive outpatient program (IOP) services. The Health Plan has denied this request indicating that the services were not and are not medically necessary for treatment of the enrollees behavioral health condition.At issue in this case is whether the intensive outpatient program services were and are medically necessary for treatment of the patients behavioral health condition.In cases such as this, an evidence based instrument such as the CALOCUS (Child and Adolescent Level of Care Utilization System) is indispensable for determining the necessary level of care for adolescents; to ensure their level of care meets their individual needs at the least restrictive setting possible. This gives the patients presentation a composite score of 19. A score of 19 correlates with a treatment intensity level of three which correlates with intensive outpatient services. This score is judged by the acuity of the patients symptoms and environment during the period in review.The progress notes indicate the patient has made some improvements behaviorally and is not aggressive or expressing active suicidal ideation. The patient continues to have a stressful relationship with family. The progress notes indicate that the patient appears to be only minimally invested in treatment and often does treatment activities to appease others. The continued group and individual therapy will be beneficial for the patient. Therefore based on the CALOCUS scoring and clinical presentation, the intensive outpatient program services were and are medically necessary. Final Result: The reviewer determined that the services 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 with subspecialty certification in child and adolescent psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 50-year-old male enrollee has requested increased testosterone injections from 100cc to 200cc weekly for treatment of his low testosterone levels.  Findings:  The physician reviewer found that the submitted information demonstrates that the requested increased dosage of medication is not medically necessary for treatment of the patients medical condition. According to American Association of Clinical Endocrinologists (AACE) guidelines, the goal of testosterone replacement is to keep testosterone in the mid-normal range. If an individuals hematocrit (HCT) is greater than 55, the dose of testosterone should be adjusted downward to avoid polycythemia. Since this patient had a mid-high normal testosterone on 100cc weekly and had a high normal HCT on 200cc weekly, 200cc weekly of testosterone is not clinically indicated. All told, an increased dosage of 200cc testosterone weekly is not supported by accepted guidelines and is not medically necessary for this patient.
Appeal type: Medical Necessity
Decision: Overturned

A 52-year-old female enrollee has requested for Remicade 5mg/kg infusions (at 0, 2 and 6 weeks and then every 4 to 8 weeks) for treatment of her rheumatoid arthritis. Findings:  The physician reviewer found that there are no guidelines to suggest the starting dose in a patient who has had improvement in the past and then wants to restart the drug.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 25-year-old female with a body mass index (BMI) of 37.3 and significant comorbid conditions.  She indicates that she has researched all the surgical procedures and has selected the duodenal switch operation for treatment of her obesity.  The patient has completed a psychological evaluation and was deemed an appropriate candidate for weight loss surgery. The Health Plan has denied coverage for the duodenal switch surgery asserting that this surgical procedure is not medically necessary for treatment of the patients condition.This patient clearly meets the criteria set forth by the National Institutes of Health for surgical treatment of obesity with a BMI of 37.3 and co-morbid conditions.  The duodenal switch operation has been shown to be effective for patients with a BMI of less than 50. Additionally, there is no data indicating that nutritional deraignment after the duodenal switch operation is any more prevalent or more serious than what is encountered with the gastric bypass operation. In fact, the lifestyle of patients after duodenal switch is generally free of the ill effects of the gastric bypass, such as the dumping syndrome and intolerance of solid foods.  As cited above, there is a large body of scientific evidence available that shows the duodenal switch operation is more durable with a better long-term success rate when compared to the gastric bypass or the Lap Band operation.  Based upon the information set forth above, I have determined the requested duodenal switch bariatric surgical procedure is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement for residential treatment center services provided for treatment of enrollee's behavioral health condition. Findings:  The physician reviewer found that to objectively determine the appropriate level of care for the patient, the case was examined using the Child and Adolescent Level of Care Utilization System (CALOCUS). This is an accepted, national standard for determining the appropriate level of care for children and adolescents. Based on these guidelines, the RTC services provided were medically necessary for treatment of this patients medical condition. The patient was at moderate risk of harm (score 3). The patients functional status demonstrated serious functional impairment (score 4) as the patient consistently has disruptive relationships with others. With this behavior, it is unlikely that the patients mother could have managed the patient as an outpatient. It would have been likely that the patient would have ended up in an inpatient psychiatric facility which would be more expensive than a RTC. The patient had significant co-morbidity (score 3). The patients recovery environment was moderately stressful (score 3), his environmental Support was supportive (score 2), and the patient demonstrated poor response to treatment (score 4). The patient was adversarial and no engaged in treatment (score 4) as he was frequently physically aggressive with staff which caused him to be restrained on many occasions. This composite score of 23 supports treatment at the RTC level of care.  Final Result:  The reviewer determined that the services at issue were medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: 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:  An enrollee requested morphine and Soma for treatment of his chronic pain.  Findings:  The physician reviewer found that the requested medications are not medically necessary. Such narcotics and at the doses prescribed is presently indicated for severe cancer pain in patients who are opioid tolerant and with a limited life expectancy. The patient has non-malignant chronic pain, which will often worsen or recur as a result of opioid rebound. The medical literature reported that high dose opiates might contribute to pain sensitization via opioid-induced hyperalgesia, decreasing patient pain threshold, and potentially mask resolution of a preexisting pain condition. In this retrospective study, the majority of patients undergoing detoxification of high dose opiates for chronic pain reported a significant decrease in pain at the end of the study, further supporting the theory of opioid-induced hyperalgesia. The medical literature reported that prolonged use of high dose opiates might induce tolerance, abnormal pain sensitivity, and hormonal effects. The medical literature also reported that carisoprodol treatment resulted in tolerance and antagonist-precipitated withdrawal, suggesting it may have an addiction potential similar to that of other long acting benzodiazepine or barbiturate compounds. This patient has been on the requested medications for a significant period of time without documentation of improved function or attempted weaning. The patient has non-malignant chronic pain, which will often worsen or recur as a result of opioid rebound. The current standard of care for chronic pain is treatment in a multidisciplinary practice to include physical therapy, massage therapy, cognitive behavioral therapy, and injections to help reduce pain. Opiates are considered adjunctive to this therapy and require close monitoring by a certified pain management physician. It is in this patients best interest to wean down or off all opiates and participate in adjunctive therapy including non-narcotic medications, physical therapy, massage therapy, or cognitive behavioral therapy, in order to address the chronic pain.Final Result: The reviewer determined that the requested medications 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 anesthesiology with sub-specialty certification in pain 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: Experimental/Investigational
Decision: Upheld

A 56-year-old female enrollee requested authorization and coverage of a Stretta procedure. The Health Plan denied the request indicating that the requested procedure is considered investigational for treatment of the enrollees gastroesophageal reflux disease (GERD).Three physician reviewers performed an experimental/investigational Independent Medical Review. All three physician reviewers concluded that the requested procedure is not likely to be more beneficial for treatment of the enrolllee's medical condition than any available standard therapy. Because all three physician reviewers concluded that the requested procedure is not likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy, the Health Plans denial has been upheld.