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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Cologuard screening for evaluation of the enrollees risk of colon cancer. Findings: The physician reviewer found that the request for Cologuard screening is medically necessary for evaluation of the patients medical condition. Cologuard is U.S. Food and Drug Administration (FDA)-approved to test for colon cancer in average-risk patients such as this patient, proved 92% sensitive for detection of colon cancer, and can detect most adenomas if they have high-grade dysplasia (Imperiale, et al). The test is recommended by the American Cancer Society guidelines. Although colonoscopy has the highest recommendation from the U.S. Preventive Services Task Force, the patient has provided a valid relative contraindication to colonoscopy. The patient will be unable to undergo bowel preparation without significant adverse symptoms and distress. For these reasons, the request for Cologuard is supported as medically necessary for colorectal cancer screening. For the reasons provided, the requested service is medically necessary for evaluation of the patients medical condition. Final Result: The reviewer determined that the requested service is medically necessary for evaluation 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 gastroenterology 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: Overturned

A 46-year-old female enrollee has requested for use of a real-time heart monitor evaluation of her hypertrophic cardiomyopathy. Findings:  Two physician reviewers found that the use of a real-time heart monitor was likely to have been of greater efficacy than other modalities for evaluating this patient.  Reiffel and colleagues examined whether the newer auto-triggered (real-time) ambulatory monitors have higher yield for the detection of both symptomatic and asymptomatic arrhythmias when compared to traditional Holter monitors and traditional event monitors.  The authors concluded that auto-triggered/real-time devices are superior to standard event monitor devices for the detection of asymptomatic arrhythmias, including atrial fibrillation. Olson and colleagues examined the performance of continuous outpatient telemetry (ambulatory monitoring with real-time capability) in a clinical setting. The authors concluded that real-time monitoring can detect asymptomatic clinically significant arrhythmias, even in patients with a previously negative workup. There is sufficient evidence demonstrating the superior efficacy of the real-time heart monitor in this clinical setting.
Appeal type: Medical Necessity
Decision: Upheld

The patient is an 18-year-old female who recently completed an inpatient course of treatment for anorexia nervosa. She had a co-morbid diagnosis of depression and was treated with Zoloft and Provigil for mood augmentation. There is no record of a trial of antidepressant medications with a stimulating effect or trials of stimulants that have been FDA approved to augment mood. The patients request for reimbursement and continuing authorization of Provigil was denied by the Health Plan based upon a determination that the medication is not medically necessary.The FDA approved indications for the use of Provigil are clearly stated and they include narcolepsy, obstructive sleep apnea/hypopnea syndrome (OSAHS), and shift work sleep disorder (SWSD). Provigil has been associated with serious side effects including abuse/dependency and cardiac arrhythmias. Additional side effects included nervousness, anorexia, depression, anxiety and hypotension. Many alternatives exist to the off-label use of Provigil such as antidepressant medications that have a stimulating effect or stimulants that have been FDA approved for mood augmentation. There are no clinical indications for the use of Provigil with this patient that fall within the FDA guidelines. Therefore, I have determined the medication at issue was/is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for total knee arthroplasty with ConforMIS Custom Implant for treatment of her knee osteoarthritis. Findings:  Three physician reviewers found that patient-specific instrumentation is a modern technique in total knee arthroplasty aiming to facilitate the implantation of the prosthesis minimizing errors in sizing, alignment, and rotation. However, review of the current literature does not indicate its recommendation as the gold standard in conventional non-complicated total knee arthroplasties. It has advantages over the conventional total knee arthroplasty in the presence of deformities, fracture malunions, and when intramedullary alignment cannot be used.  However, for a standard total knee arthroplasty such as in this case, the current literature does not support the use of patient specific instrumentation. Per the medical evidence, the requested services are not likely to have a better result compared to the standard total knee arthroplasty. 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: Reviewers 1, 2, and 3 are 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 64-year-old female has requested hyaluronic acid injections with Euflexxa for treatment of her left knee pain.  Findings:  The physician reviewer found that based on review of the available records, it is not medically necessary for this patient to receive hyaluronan injections into the left knee. Overall, the efficacy of hyaluronan in patients where there is good documentation of a meniscal tear is unsupported. Hyaluronan has not been shown to address the meniscal tear itself. The presence of repeated documentation of symptoms, probably originating from meniscal tear, would indicate that there may be a positive benefit from an arthroscopic debridement even though the patient has associated medial compartment degenerative changes. The use of hyaluronan is poorly documented in the literature. The articles published all lend very little support to hyaluronan in treating osteoarthritis of the knee. In this patients case with evidence of a meniscal tear on MRI, it is even more unlikely that the administration of hyaluronan would have any useful effect.
Appeal type: Medical Necessity
Decision: Upheld

A 42-year-old female enrollee requested authorization and coverage of gastric bypass surgery. The Health Plan denied the request indicating that the requested procedure is not medically necessary for treatment of the enrollees obesity.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested procedure is not medically necessary.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for botulinum toxin (Botox) injections.Findings:  Three physician reviewers found that the current medical evidence supports the services at issue in this patients case. Botox injections have been demonstrated to be effective for the treatment of chronic migraine. This patients records document the diagnosis of chronic migraine, and she experienced a reduction of headache days per month following treatment with Botox injections. The U.S. Food and Drug Administration has approved Botox injections for the treatment of chronic migraine. In sum, botulinum toxin (Botox) injections were and are likely to be more efficacious than other available treatment modalities. Final Result: The reviewers determined that the services at issue were and are 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 neurology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/ Case Summary:  The enrollee requested reimbursement for immunoassay, spectrophotometry and column chromatography/mass spectrometry. The enrollee has a history of viral versus autoimmune meningoencephalitis, seizure disorder and anxiety. The enrollee continues to demonstrate severe anxiety and symptoms of an overstimulated nervous system, despite high doses of anti-epileptic medications. He complains of blurry vision and episodes of vertigo. He underwent a NutrEval, which showed a need for thiamine (vitamin B1) and magnesium. It also showed borderline whole blood mercury, antioxidants within range, and positive dysbiosis markers. The enrollees provider recommended benfotiamine daily, magnesium threonate, twice daily and biocidin for treatment of fungal dysbiosis. Labs were re-checked, which showed normal C3/C4 protein levels and elevated serum CH50 levels. Past blood and immunology tests have been inconclusive. The laboratory tests were ordered to find the cause of why a healthy, active man went into a coma within 48 hours after admission to the hospital, with continual seizures. The goal is to prevent possible flare-ups or setbacks. This enrollee was assessed with a comprehensive digestive stool analysis 2.0 (CDSA 2.0) and a nutritional evaluation (NutrEval). Researchers claim these tests offer insight into the individuals functional status with regard to several of the proposed core pathways comprising functional medicine. The clinical trials will need to demonstrate efficacy of the functional medicine approach before its incorporation into clinical practice. The manufacturer describes the NutrEval profile as a laboratory panel designed to give physicians a better understanding of individuals' nutritional deficiencies. There is minimal available peer-reviewed literature regarding the NutrEval test panel. There is no documentation to support why the enrollee needed chromatography/mass spectrometry.  Final Result: Three of the three reviewers determined that the requested services were not likely to have been more beneficial than any available standard therapy for treatment of the enrollees medical condition. Credentials/Qualifications: Three reviewers are board certified in neurology 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: Medical Necessity
Decision: Upheld

A 55-year-old female enrollee requested codeine sulfate 60 mg and acetaminophen-codeine 300 mg-60 mg for medical treatment of her shoulder pain status post right shoulder surgery.  Findings:  The physician reviewer found that based on the available medical records, the request is not medically necessary for management of this patients right shoulder pain status post shoulder surgery. The patient has been on these medications for over one year without documentation of improved function or attempted weaning.  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. All told, the requested codeine sulfate 60 mg and acetaminophen-codeine 300 mg-60 mg is not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a 16-year-old female enrollee requested psychiatric residential treatment for treatment of the enrollees behavioral health conditions.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  The record does not demonstrate that the patient had failed less restrictive levels of care, non-pharmacological interventions, family counseling, or evidence-based psychotherapies and psychopharmacological strategies targeting her psychiatric diagnoses.  There was no elaboration of the longitudinal symptom evolution and its subsequent burden.  There was no discussion of past treatments or relevant psychosocial factors and support systems.  There was no explanation opined by the treatment team articulating the value of the wilderness setting as opposed to comprehensive clinical interventions in a less restrictive environment.  In the absence of such clinical documentation, the medical necessity of the services at issue cannot be established.  All told, psychiatric residential treatment was not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent an enrollee has requested coverage for 30 hours per week of direct intervention applied behavioral analysis (ABA) therapy. On review of the available records, 30 hours per week of direct intervention ABA therapy, to be administered in home and community settings, is supported as medically necessary for this patient based on current available medical literature and National Autism Center guidelines. To determine the medical necessity of ABA, researchers provide guidelines. According to the researchers, 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. Further, the Behavior Analysis Certification Board (BACB) indicates that treatment for autism can be focused with 25 hours or less per week, or comprehensive with 30-40 hours per week. The BACB notes that behavior that threatens the health or safety of the client or that constitutes a barrier to quality of life should result in more intensive ABA services. In this case, the patient presents with pica, which poses a threat to his safety. He continues to require continuous monitoring and intervention. While comprehensive ABA therapy is appropriate, the setting of implementation must be considered. The patients provider reports document minimal parental involvement with the patients treatment. Moreover, the majority of ABA hours have been provided within the school setting. Thus, provision of ABA services within the home and community settings would foster parental involvement and maximize treatment outcomes across settings. Accordingly, 30 hours per week of direct intervention ABA therapy, to be administered in home and community settings, is supported as medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that of 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 psychology and am a board certified behavioral analyst 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 has requested authorization and coverage for Taltz for treatment of the enrollees plaque psoriasis. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication in this clinical setting. There is a lack of documentation that indicates that this patient has tried and failed methotrexate, cyclosporine, acitretin, Enbrel or Humira. The patient is BRCA2 positive, but the medical evidence does not show that use of Taltz over methotrexate, cyclosporine, acitretin, Enbrel or Humira confers any medical advantage.  The documentation of adverse effects or contraindication to the use of the methotrexate, cyclosporine, acitretin, Enbrel or Humira has not been documented in this patient. As such, Taltz is not medically necessary for the treatment of this patients medical condition. 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 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the residential treatment center (RTC) level of care services he received. Findings:  The physician reviewer found that the patient continued to meet criteria for RTC level of care services during the period in dispute. The records demonstrate that he had not developed coping strategies or the ability to maintain sobriety if he were to be discharged to a lower level of care. In addition, there was continued family dysfunction such that the patients home environment would likely not have afforded the structure and boundaries needed for the patient to avoid a relapse if he were discharged from the 24-hour RTC facility. All told, the RTC level of care services provided were medically necessary for treatment of this patients behavioral health issues. 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: The patient has requested reimbursement for skilled nursing facility (SNF) services. The records document that this patient has multiple chronic medical conditions associated with long-term health problems and functional difficulties including heart disease, diabetes, kidney disease, and arthropathy. At premorbid baseline, the patient was using a walker, but was independent with basic self-care and basic mobility. He was documented as requiring assistance with his instrumental activities of daily living at baseline. The patient had multiple acute hospital care episodes related to anemia, congestive heart failure, renal failure, urinary obstruction, dehydration and near syncope. He developed general physical debility and was dependent for essentially all aspects of care. There was also reports of confusion. The patient underwent therapy and convalesced at a SNF. However, the records do not report that the patient substantively improved during this time. The patient was discharged to the long-term care unit of the facility. He was at a low functional level at the time and required total assistance for all mobility. Over the ensuing months, the patient demonstrated generalized functional improvement without documented skilled therapy intervention. On therapy re-assessment, the patient required contact guard to minimum assistance for transfers and ambulating short distances with a walker at minimum assistance. The patient required set up for upper body self-care such as feeding and upper body dressing. There are no documented indications that therapy continued after the assessment. The patient was cleared for leaves of absence from the facility with family. He underwent further therapy, but he was essentially requiring cues and contact guard assistance to complete his basic self-care and mobility tasks. He continued to require significant levels of cues despite the ongoing therapy. There were no indications that this level of supervision and assistance could not have been supplied by custodial level caregivers in the community or that the patient was benefiting from formal therapy services. He had chronic medical issues but no ongoing issues requiring inpatient level care or monitoring. He was receiving medical care consistent with outpatient level care and his nursing needs were custodial. The indwelling urinary catheter was no longer an acutely placed device but a chronically maintained device. All told, the SNF services were not medically necessary for treatment of this patient.  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 physical medicine and rehabilitation 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.