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

Nature of Statutory Criteria/Case Summary:  An enrollee has requested genetic testing for the evaluation of her medical condition.  Findings:  Three physician reviewers found that in general, the practice of pharmacogenetics, or the tailoring of a medication regimen based on an individuals genetic organization, may well become a valuable tool in the treatment armamentarium for those plagued with psychiatric illness.  However, despite its promise, pharmacogenetics is not yet ready for mainstream clinical application.  In this patients case, the clinical documentation failed to support the necessity of genetic testing.  There was no discussion of prior interventions used to treat depression.  Without the review of the specific type, setting and duration of psychotherapies, or, the selection, dosing and length of previous psychotropic medication trials, it cannot be inferred that the patient had exhausted standard treatments available to treat her condition.  The records do not demonstrate that the services at issue yielded information that significantly influenced treatment decisions, improved the patients condition, prevented a more serious episode of illness or reduced morbidity.  Thus, genetic testing was not likely to have been of greater benefit than other modalities.  Final Result: Three reviewers determined that 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:  All three reviewers are board certified in psychiatry and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

The authors noted that viscosupplementation was not superior to the use of a corticosteroid injection. Maheu and colleagues recommended intra-articular hyaluronic acid (IAHA) injections as a treatment option in the management of knee osteoarthritis, tailored by disease stage and patient phenotype. The authors indicated that future research efforts should focus on identification of osteoarthritis patient subgroups that demonstrate a more robust response to IAHA, determination of long-term effects of repeat IAHA injections on patient-reported outcomes and total knee replacement-sparing effect, further elucidation of disease-modifying effects, and the potential for combination therapy with other pharmacologic and non-pharmacologic therapies to optimize the management of knee osteoarthritis.This patient presents with left knee pain that interferes with activities of daily living. Clinical examination findings are consistent with radiographic evidence of minimal to mild medial and patellofemoral compartment osteoarthritis. Her prior conservative treatment has included a corticosteroid injection on 4/02/19, with no documentation of response. Over-the-counter nonsteroidal anti-inflammatory drugs have not been beneficial. The physician reviewer found that the current literature does not support the use of viscosupplementation in the setting of mild knee osteoarthritis. Detailed evidence of a recent, reasonable and/or comprehensive non-operative treatment protocol trial and failure has not been submitted. Thus, Euflexxa injections in the left knee are not likely to be of greater benefit than other treatment options.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for computed tomography (CT) scan of the heart for evaluation of the enrollees family history of heart disease.  Findings:  The 3 physician reviewers found that based on the records provided the patient is a male with a family history of coronary disease, no documented cardiac symptoms, and a normal cardiovascular physical examination. In this circumstance, guidelines for the evaluation and management of coronary risk recommend using the combination of clinical risk profiling in conjunction with a basic lipid analysis. Current guidelines by the American College of Cardiology and American Heart Association do not recommend screening with coronary calcium scanning in this setting. Therefore, the request for CT scan of the heart is not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: The 3 reviewers determined that the requested service is 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 reviewer number one is board certified in internal medicine with sub-specialty certification in cardiovascular disease 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 cardiovascular disease 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 cardiovascular disease 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 parent of a nine-year-old male enrollee has requested acute inpatient psychiatric treatment for treatment of the enrollees behavioral health problems. Findings:  The physician reviewer found that there is sufficient documentation to support acute hospitalization during the dates of service in question. This patient presented with complex psychiatric disorders. The level of care provided is consistent with the Child and Adolescent Level of Care Utilization System. Based on these criteria, the patients functional impairment was severe which would be rated a 5. His co-morbidity issues were major (Tourettes syndrome and ADHD seriously complicated by autism spectrum disorder) and would also be rated a 5. A rating of 5 in just these two domains alone requires treatment in a secure 24-hour setting. The level of care provided is also consistent with American Academy of Child and Adolescent Psychiatry Practice Parameters for treatment of children with autism.
Appeal type: Medical Necessity
Decision: Overturned

A 39-year-old female enrollee has requested individual intensive outpatient psychotherapy five times weekly for treatment of her bipolar disorder. Findings:  The physician reviewer found that based on medical documentation, the medical necessity for psychotherapy five times per week is not apparent. There was evidence of improvement since the progress notes, and no severe symptoms were described. Several symptoms were rated mild on the date in question. The article by Miklowitz indicated that psychotherapy and psychosocial interventions are beneficial in the treatment of bipolar disorder, and such interventions can be tapered to less frequent sessions based on clinical functioning. In this patients case, based on medical documentation, it was reasonable to taper the frequency of sessions from five sessions per week to three sessions per week as of the said date.  Thus, from the date in question going forward, although five sessions per week were not and are not medically indicated, three sessions per week were and are medically indicated for this patient.
Appeal type: Experimental/Investigational
Decision: Overturned

An enrollee has requested reimbursement for Doppler-guided transanal hemorrhoidal dearterialization. Findings:  Two of the three physician reviewers found that per American College of Gastroenterology guidelines, Doppler-assisted hemorrhoidal artery ligation has success rates comparable to hemorrhoidectomy and stapled hemorrhoidopexy. Studies have shown that it is comparable to conventional surgical hemorrhoidectomy for advanced hemorrhoidal disease in efficacy and safety. Given lower post procedure pain compared with alternatives, Doppler-assisted hemorrhoidal artery ligation has been reported as first-line treatment in the setting of grade 3 hemorrhoids. The procedure can include repair of mucosal prolapse. The technique at issue preserves the anatomy and physiology of the anal canal when compared to other surgical treatments for hemorrhoids, averting impaired anal function and fecal incontinence. For these reasons, Doppler-guided transanal hemorrhoidal dearterialization was likely to have been of greater benefit than other available treatment options. Final Result: The reviewers determined that the services at issue were likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in gastroenterology 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: Overturned

Nature of Statutory Criteria/Case Summary: A patient has requested reimbursement for residential treatment center services. The Health Plan has denied this request indicating that the services at issue were not medically necessary for treatment of the patients behavioral health conditions. The submitted documentation supports the medical necessity of the services at issue. Medical guidelines for eating disorders recommend that the standard of treatment is either an inpatient unit or residential treatment facility when lower levels of care have been tried and failed, and further that the presence of comorbid conditions is an important factor to be considered when deciding on a level of care. A study conducted of treatment results of anorexia nervosa and bulimia nervosa in a residential treatment program noted that for patients with anorexia nervosa (AN), there were statistically significant improvements in mean BMI. In addition, for both AN and bulimia nervosa patients, there were statistically significant improvements in Beck depression inventory (BDI) scores, all 11 eating disorder inventory (EDI)-2 subscales, and frequencies of bingeing, vomiting, laxative abuse, chewing and spitting, stimulant abuse, and restricting behavior. The great majority of patients completing treatment showed significant improvement at discharge from intensive residential treatment. In this case, the patient was experiencing a disturbance in mood, affect, or cognition resulting in disordered eating behavior that could be safely managed in a less restrictive setting. Thus, residential treatment was in accordance with generally accepted standards of medical practice, clinically appropriate for the patient's illness, not more costly than an alternative service for treatment of the patients condition, and was therefore medically necessary. Accordingly, the residential treatment center services were medically necessary for the treatment of this patient.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 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 is a three-year-old female with a history of multiple emergency room visits due to seizures. The patients provider has documented episodes of seizures lasting 45 to 60 minutes associated with perioral cyanosis lasting 10 to 15 minutes. In-home oxygen has been recommended by the patients provider. The Health Plan has denied authorization and coverage for the requested equipment on the basis that it is not medically necessary.The Health Plans denial should be overturned. A three-year-old female who has up to 60-minute seizures with perioral cyanosis is a reasonable candidate for supplemental oxygen. The patient has a history of multiple emergency room visits. An in-home oxygen tank is medically reasonable and appropriate and is indicated given the duration and frequency of the patients seizures. Therefore, I have determined that the requested equipment is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

A 47-year-old female enrollee requested authorization and coverage of 18 Imitrex 100mg tablets per month. The Health Plan denied the request indicating that the requested prescription is not medically necessary for treatment of the enrollees migraine headaches.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plans denial on the basis that the requested prescription is medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

A 48-year-old female enrollee has requested Nuvigil for treatment of her fatigue due to multiple sclerosis. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication.  Neither Provigil nor Nuvigil has been shown to be significantly effective for treatment of multiple sclerosis-related fatigue.  However, these medications have been used to treat multiple sclerosis-related fatigue in patients who have failed standard therapies.  In this case, the patient has tried and failed amantadine, but not Provigil.  The Health Plan states that they will cover Provigil.  Nuvigil has not been shown to be superior to Provigil in the treatment of fatigue or excessive daytime somnolence.  Therefore, Nuvigil is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

A 40-year-old female enrollee has requested Provigil for the treatment of her fatigue related to systemic lupus erythematosus (SLE) and fibromyalgia. Findings:  The physician reviewer found that the EE's symptoms are primarily related to her fibromyalgia. However, there may be other contributing factors. The patient is diagnosed with SLE; fatigue along with this diagnosis may indicate the illness itself is not under control. Provigil has specific FDA-approved indications, which do not include SLE or fibromyalgia. Safety and efficacy have not been established for those conditions.
Appeal type: Medical Necessity
Decision: Upheld

A 61-year-old female enrollee has requested for a SPECT stress test for evaluation of her coronary artery disease. Findings:  The physician reviewer found that the patient has significant cardiac risk (hypertension, dyslipidemia and family history of coronary disease), coronary calcification and atypical non-exertional shoulder discomfort that was not reproduced during exercise. There was no chest discomfort and no ischemia by echocardiographic imaging, but there was an ischemic appearing ECG response on the same stress echocardiogram. There was no report of technical limitation during echocardiographic imaging.  In this circumstance of no provocable symptoms and no provocable ischemia on technically adequate echocardiographic imaging, the electrocardiographic changes observed may represent a false positive response.  Additional exercise stress testing of any sort would likely elicit similar electrocardiographic changes and therefore likely would not provide significant incremental information to what is already known.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 14-year-old male enrollee has requested acute inpatient psychiatric treatment services for the treatment of the enrollees behavioral health problems. Findings:  The physician reviewer found that there may well be a manipulative element to his behavior, but this does not obviate the need for much more intensive services than the patient himself would have allowed for on an outpatient basis. A week of inpatient evaluation and treatment was needed to ascertain what was transpiring with the patient and his family, and to have a better sense of therapeutic direction.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for 30 hours per week of direct applied behavioral analysis (ABA) therapy and three hours per week of supervision for treatment of the enrollees autism. Findings:  The physician reviewer found that several studies recommend 25 or more hours of weekly ABA to ensure optimal outcomes. Moreover, Ample research has shown that intensive applied behavior analysis (ABA) treatment produces robust outcomes for individuals with autism spectrum disorder (ASD). A study of 726 children (ages 1.5 to 12) to evaluate the relationship between treatment intensity and treatment outcomes. The study showed a strong relationship between treatment intensity and mastery of learning objectives, where higher treatment intensity predicted greater progress. In this case, the patient has made progress with ABA therapy as evidenced by the behavioral data submitted, but he continues to have problematic behaviors which include vocal stereotypies, visual self-stimulating behaviors, self-injurious behaviors and pica. 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. Credentials/Qualifications: The reviewer is board certified in pediatrics with sub-specialty certification in developmental-behavioral pediatrics 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 49-year-old male has requested treatment at the Los Angeles Clinic and Research Institute for treatment of prostate cancer.  Findings:  The physician reviewer found that there is no evidence of any one androgen deprivation regimen that is clearly superior in survival or complications over the others. The literature generally supports a combined regimen of hormonal therapy and radiation for advanced and mid to high-grade prostatic carcinoma. The optimal schedule of hormonal therapy is debatable and still under investigation. Additional consultations would be likely to yield additional recommendations in regard to the androgen deprivation regimen. It cannot be said that the treatment plan offered by the Angeles Clinic is superior to the one offered by the in-Plan specialists.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 15-year-old female enrollee has requested  for mental health acute inpatient treatment for treatment of the enrollees behavioral health issues.  Findings:  The physician reviewer found that this patient has a recent history of multiple suicide attempts, self-abuse, and threats of harm to other people. She remained delusional and psychotic, and given her history of self-harm, met the American Psychiatric Association (APA) criteria for inpatient mental health services.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 17-year-old male enrollee has requested partial hospitalization program (PHP) as opposed to inpatient treatment for the enrollees behavioral health issues.  Findings:  The physician reviewer found that based on review of the available records, the patient presents with signs of depression including passive suicidal thoughts, stating that he wished he could die, but that he would not hurt himself and put his family through the pain of his actions. Apparently, both the patient and the parent agreed that PHP is appropriate and that he would be attending voluntarily with his parents full support. The records indicate this patient meets the criteria for PHP, but does not at all meet criteria for inpatient level of care as he is not making suicidal threats, has no suicidal plan, has never made a suicide attempt, has never threatened to hurt himself, is not psychotic, and the patient and his family have been cooperative. All told, the records support the requested PHP level of care services for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 42-year-old female enrollee has requested sub acute residential detoxification services for the treatment of her behavioral health problems. Findings:  The physician reviewer found that the specific need for sub acute detoxification is not clearly shown in the medical record; there was no detoxification - treatment plan found. That patients progress is described in physician notes, but it is unclear what protocol, if any, he was following. The information provided does not demonstrate that at the time of transfer to subacute care the patient had any mental status abnormality of documented withdrawal symptoms. Although psychiatric consultations were obtained, there is no specific indication that the patients condition required treatment beyond that of an outpatient program. She was not psychotic, suicidal or homicidal. The patient was treated with acupuncture, massage and various medications, but it is unclear what the specific goals of the subacute detoxification actually entailed.The record does not demonstrate the patients potential for clinically significant withdrawal requiring 24 hour medical intervention. Active withdrawal symptoms are not described. In addition, the patients associated psychiatric condition does not require inpatient care. While medications were ordered there was no specific medication management of withdrawal symptoms.
Appeal type: Experimental/Investigational
Decision: Upheld

A 69-year-old male enrollee has requested genotype testing for polymorphisms for evaluation of the enrollees drug metabolizer status.  Findings:  Three physician reviewers found that genotype testing for polymorphisms is not likely to be more beneficial for treatment of this patients medical condition than any available standard therapy. Genetic testing in this case is not appropriate, as it does not demonstrate any contribution towards improving or adding to treatment of the patients condition. The current standard of care for chronic pain is treatment in a multidisciplinary practice to include physical therapy, massage therapy, behavioral therapy, and injections to help reduce pain. Opioids are considered adjunctive to this therapy and require close monitoring by a certified physician (Fishman). Therefore, the requested genotype testing for polymorphisms to determine the patients drug metabolizer status is not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.