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

Nature of Statutory Criteria/ Case Summary:  The parent of an enrollee has requested reimbursement  for wilderness therapy services. The enrollee has major depressive disorder and anxiety. She has a history of self-harm, suicidal ideation, and suicide attempts. The medical literature  recommends the least restrictive setting for treatment that will address the patients safety and promote improvement in the patients condition. Consideration of the patients symptom severity, co-occurring psychiatric or general medical conditions, available support system, and level of functioning must be given. The optimal treatment setting and the enrollees likelihood of benefit from a different level of care should be re-evaluated on an ongoing basis throughout the course of treatment. Review of the records indicates the enrollee had committed serious acts of self-harm prior to the partial hospital program. However, there is insufficient evidence in the records to support the requested treatment. Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The clinical reviewer is board certified 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The case involves a 48-year-old patient who presented with the complaint of intermittent menstrual periods, which she describes as heavy and painful. The patient was also diagnosed with hypothyroidism, and although on synthroid, still has an elevated TSH.Of note, the patient has been on hormone replacement therapy (HRT) since April 2005, which was started for unclear reasons prior to the cessation of her own menses. The patient had an ultrasound that revealed a small probable intramural fibroid (1.5 cm), a normal endometrial echo complex, a normal left ovary and a surgically absent right ovary. She was referred to a gynecologist who recommended a total abdominal hysterectomy with bilateral salpingo-oophorectomy (TAH-BSO) (although the record refers to the patient as having has a prior right oophorectomy) for pain and bleeding, and a Marshall-Marchetti procedure for leaking urine with cough and sneezing.At issue is whether the proposed surgery is medically necessary for treatment of the patients medical condition.The clinical evidence does not demonstrate the proposed surgery is medically necessary. A 1.5cm intramural fibroid is insignificant and it is unlikely to be causing pain. With a normal endometrial complex, it is also unlikely that the fibroid impinges on the endometrium and therefore should not be the cause of heavy menses. In addition, the patients pain is not well documented and it is presumptuous to assume that a TAH-BSO will alleviate all of the pain, as is the patients expectation. Furthermore, there is no documentation either by physical exam or laboratory evaluation of urethral hypermobility or intrinsic sphincter deficiency that could be corrected surgically and result in resolution of the patients urinary stress incontinence. Moreover, there is no documentation of an attempt to treat the patients bleeding and pain medically with either NSAIDs or oral contraceptives. ACOG criteria for a hysterectomy performed for either pain or bleeding require that there be a failure of medical therapy prior to surgery. It should also be noted that the patient has been on HRT for more than one year and it is possible that this is contributing to the pain and/or bleeding, as it is not at a sufficient dose to suppress her intrinsic hormonal production. In summary, the submitted clinical information does not document any trial of medical therapy and sufficient preoperative evaluation to support the proposed surgery in this case. Accordingly, I have determined the requested surgery is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Restasis cyclosporine eye drops. Findings: In a systematic review to evaluate the safety and efficacy of topical cyclosporine in treating patients with dry eye syndrome, a study concluded that twice daily application significantly improved both objective and subjective outcomes. Another study notes that there is consistent evidence of objective improvements in chronic dry eye disease with the use of cyclosporine ophthalmic emulsion 0.05%. Patients with recalcitrant dry eye disease underlying inflammation are most likely to respond to this medication. Given that the records show that the patient has continued symptoms despite already been using artificial tears and has a diagnosis of Hashimotos disease, which may result in underlying inflammation, the requested medication is medically indicated. Therefore, Restasis cyclosporine 0.05% eye drops are 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 ophthalmology 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 52-year-old female enrollee requested authorization and coverage of continued chiropractic therapy. The Health Plan  denied the request indicating that the requested therapy is not medically necessary for treatment of the enrollees neck pain.One chiropractic reviewer performed a medical necessity Independent Medical Review. The chiropractic reviewer upheld the Health Plans denial on the basis that the requested therapy is not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for residential treatment center (RTC) services. The American Association of Community Psychiatrists Level of Care Utilization System (LOCUS) provides a reliable framework for determining the appropriate level of care for adults needing mental health treatment. Applying LOCUS guidelines, this patient meets the criteria for RTC level of care services. The patient has demonstrated some risk of self-harm (score 2) given her reports of passive suicidal ideation. The patient has also been hydroloading. The patient has shown severe functional impairment (score 4) as she has not been attending to ADLs. The patient has significant comorbidity (score 2) with tachycardia as well as orthostatic hypotension as a result of her food restriction. The patients recovery environment is moderately stressful (score 3). The records document that the patient lives with her mother, who also has psychiatric issues. The patients recovery environment is supportive (score 2) as she lives with her mother. The patient has demonstrated moderate response to treatment (score 3) due to her eating disorder that started in her teenage years. The patient has been constructive in treatment (score 2) as the provider noted that the patient has been adherent with treatment although she struggles with her eating plan. This gives the patient a composite score of 18, which is consistent with high intensity community based services. However, the patients score of 4 for functional status supports medically monitored residence based services, such as RTC level of care. RTC for eating disorders is an intensive group-based and individual intervention, with 24-hour monitoring and 12 or more active hours of treatment daily. This intermediate level of care can treat many of the acute aspects of eating disorders. Given these findings, the RTC level of care services were and are medically necessary for treatment of this patient.Final Result: The reviewer determined that the services at issue were and are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A female enrollee requested hormone pellet implants for treatment of her artificial menopause status post total abdominal hysterectomy. Findings:  Three physician reviewers found that bioidentical hormone therapy is considered controversial and is not supported by the American Association of Clinical Endocrinologists (AACE) or Endocrine Society. Moreover, preparations vary widely including the type of hormonal preparation and the dosages used. There is controversy as to what hormone assay should be used to measure levels and the proper treatment range. All told, there is a paucity of peer-reviewed medical literature supporting the long-term safety and efficacy of the requested hormone pellet implants as likely to be more beneficial than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient is a male who has requested reimbursement for residential treatment center (RTC) services. The Health Plan denied the request as not medically necessary.The American Psychiatric Association treatment guidelines for substance use disorders recommend that residential treatment or similar care, higher than outpatient, is indicated for patients who do not meet the clinical criteria for hospitalization but whose lives and social interactions have come to focus predominantly on substance use, lack sufficient social and vocational skills and drug-free social supports to maintain abstinence in an outpatient setting.Patients require safe and stable living environments in order to develop their recovery skills, thus qualifying for ASAM (American Society of Addiction Medicine) Level III treatment at least i.e., similar to what the patient received at the facility.In this case, the patient had no home during the dates at issue. Despite multiple attempts at lower levels of care, he continued to use risky and life-threatening substances. He did not attend to his basic personal activities of daily living. Given the severity of his illness, RTC services were in accordance with generally accepted standards of medical practice, clinically appropriate for his illness and medically necessary. 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: Overturned

A 56-year-old male enrollee has requested for continued acute inpatient hospitalization for treatment of his depression. Findings:  The physician reviewer found that this patient presents with severe depression and psychotic features along with hopelessness, poor eye contact, and impaired judgment. He remains at high risk for self-harm and at risk for impaired self care. The patient has not improved to the point that he is stable for transition to a less intensive level of care. He is in need of treatment in a 24-hour hospital setting with close observation, ongoing monitoring and intensive treatment.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for magnetic resonance imaging (MRI) of the right knee. Researchers do not recommend the systematic use of imaging in the diagnostic process in cases with typical clinical presentation of osteoarthritis, or the use of routine imaging in osteoarthritis follow-up. The authors further note that imaging abnormalities of osteoarthritis are commonly seen especially with increasing age. In this case, the patient has arthritis of the knees. Given that the submitted records did not document mechanical symptoms such as intermittent catching or effusion, and did not include a discussion of the trial and failure of conservative care, the service at issue was not medically indicated. Therefore, MRI of right was not medically necessary for the evaluation of this patient.Final Result: The reviewer determined that 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

The patient has requested authorization and coverage for a glucose monitor. Many patients monitor their blood glucose levels at home to help sustain reasonable blood glucose control and avoid associated short- and long-term diabetic complications (Zheng, et al.). The introduction of continuous glucose monitors (CGMs) has improved the ability of patients to monitor their glycemic control without the need for finger sticks (Olczuk and Priefer). The FreeStyle Libre CGM is a wireless device using a sensor for monitoring interstitial fluid glucose that was introduced to help patients with type 1 and 2 diabetes mellitus achieve better glucose control. The FreeStyle Libre CGM, unlike other devices, does not require finger stick calibration. Recent data suggests that the FreeStyle Libre CGM is accurate, and patients report excellent satisfaction with use of the device (Olafsdottir, et al.). Given this support, the requested glucose monitor is medically necessary for treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Overturned

A 62-year-old male enrollee has requested an F-DOPA positron emission tomography (PET) scan of the brain for an evaluation of his progressively worsening tremors. Findings:  Three physician reviewers found that although an F-DOPA PET scan is not a standard test for the diagnosis of Parkinsons disease, it is indicated and medically appropriate in this particular case. This patient has refractory progressive symptoms. Currently, the patients neurologist is considering the diagnosis of conversion disorder as opposed to Parkinsons disease. The use of the proposed study will be very useful in differentiating between these two conditions and is supported by the medical literature. In this case, this imaging study is crucial as it will help provide a diagnosis and guide future therapy.
Appeal type: Experimental/Investigational
Decision: Overturned

 A male enrollee requested intensity modulated radiation therapy (IMRT) and real-time intra-fraction target tracking for medical treatment of his high-grade retroperitoneal sarcoma.Findings:  Two physician reviewers found that IMRT was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. IMRT is the standard of care in this clinical scenario and was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.  Retroperitoneal sarcomas are generally fixed to the retroperitoneum and not subject to much respiratory motion.  Real-time intra-fraction target tracking was not likely to be more beneficial for treatment of the patients medical condition than standard therapy.   A portion of the services at issue were likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 23-month-old male enrollee has requested the VEST Airway Clearance System (CPT E0483) for treatment of the enrollees chronic congestion and hypotonia.  Findings:  The physician reviewer found that high-frequency chest wall oscillation (HFCWO) systems such as the VEST System were developed to improve airway clearance in those patients in whom the normal mucociliary transport system has failed (e.g., chronic bronchitis, bronchiectasis, cystic fibrosis). The majority of patients in whom airway clearance systems have been studied have cystic fibrosis. In stable outpatients with cystic fibrosis, high-frequency oscillation and chest physiotherapy were found to have comparable augmenting effects on expectorated sputum weight without changing PFTs or oxygen saturation. In a different study of cystic fibrosis patients, both wet and dry expectorated secretion weights were greater with HFCWO compared to CPT, suggesting HFCWO is at least as effective as manual CPT/PD (postural drainage) in clearing secretions from the airways in patients with cystic fibrosis. VEST therapy has also been studied in children with quadriplegic cerebral palsy. In one study, VEST therapy resulted in more effective suctioning of pulmonary secretions, reduced incidence of pneumonia, and reduced number of hospitalizations for pneumonia. In another study of 28 patients with cerebral palsy and neuromuscular diseases, compliance with treatment was higher with high-frequency chest wall oscillation than with standard CPT. Furthermore, in patients with familial dysautonomia, available data demonstrates HFCWO resulted in significant improvements in all health outcomes and oxygen saturation. In summary, VEST therapy has been shown to be at least as effective as manual CPT when manual CPT can be done appropriately. For this patient, manual CPT is not a reasonable option; proper positioning places him at risk for aspiration due to gastroesophageal reflux and difficulty handling secretions. He cannot use other devices (e.g., Flutter device) because he does not have the cognitive ability necessary to complete the therapy. The VEST System has been studied in multiple populations with airway clearance issues and has been found to be an effective means of clearing airway secretions, decreasing the need for hospitalization from pneumonia. Use of VEST therapy is medically necessary and appropriate for this patient to improve airway clearance and prevent unnecessary complications.
Appeal type: Medical Necessity
Decision: Overturned

Findings:  The physician reviewer found that The patient has requested authorization and coverage for proton beam therapy (33 units each of proton treatment delivery simple without compensation (CPT code 77520), proton treatment delivery intermediate (CPT code 77523), and proton treatment delivery complex (CPT code 77525). Kammerer and colleagues report that proton therapy reduces mean heart dose in breast cancer irradiation, probably reducing late cardio-vascular toxicity. Hug notes that in a small but significant percentage of patients requiring adjuvant radiotherapy for left-sided breast cancer, photon-based radiotherapy can lead to cardiac complications during long-term follow-up. The author further notes that proton therapy reduces the integral dose received by normal tissues. In this case, the provided proton/photon plan comparison shows that a photon radiation treatment plan results in excessive heart exposure, leading to an unacceptable and unnecessary risk for cardiac morbidity and mortality, while the proton radiation plan significantly reduces the cardiac exposure to within known safe tolerance limits. In this clinical setting, given that the patient cannot be treated safely and/or effectively with the use of photon-based radiotherapy, the requested services are medically indicated. Therefore, proton beam therapy (33 units each of proton treatment delivery simple without compensation (CPT code 77520), proton treatment delivery intermediate (CPT code 77523), and proton treatment delivery complex (CPT code 77525) are medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: an enrollee has requested authorization and coverage for Victoza. Findings:  The physician reviewer found that Victoza is a glucagon-like peptide-1 receptor analog (GLP-1 RA). Glucagon-like peptide-1 (GLP-1) based therapies affect glucose control through several mechanisms, including enhancement of glucose dependent insulin secretion, slowed gastric emptying, and reduction of postprandial glucagon and of food intake. Victoza is indicated in the treatment of diabetes mellitus and obesity. One study demonstrated that GLP-1 is associated with inappropriate increase in insulin secretion, and this mechanism is responsible for post-bariatric hypoglycemia. Based on these findings, use of Victoza may cause worsening of the patients post-bariatric hypoglycemia. 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 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: Upheld

A 37-year-old male enrollee has requested for inpatient hospital stay for treatment of his ulcerative colitis. Findings:  The physician reviewer found that there is inadequate evidence to support the contention that the patient required an acute level of care.
Appeal type: Medical Necessity
Decision: Upheld

The patient has requested authorization and coverage for a positron emission tomography (PET) scan. There is no cytological diagnosis of cancer in this patient included in the records provided for review. The patient reports the lesion at T11-12 is a Schwannoma, which is a benign nerve sheath tumor not prone to metastases. Evaluation for local growth is recommended with magnetic resonance imaging (MRI). The patient was evaluated with MRI scans both pre-operatively, and post-operatively, which were interpreted as unchanged. The literature shows some potential benefit of PET in searching for spinal metastases when a malignant primary tumor has been confirmed. However, there is a lack of evidence that PET is useful in differentiating a benign Schwannoma from a malignant nerve sheath tumor. All told, the requested PET scan is not supported as medically necessary for further evaluation of this patient. Final Result: The reviewer determined that the requested services are 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 radiology 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.