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

Nature of Statutory Criteria/Case Summary: An enrollee has substance abuse residential treatment center services 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.  Although chemical dependency specialty services were indicated, the medical records do not demonstrate the necessity of the residential level of care.  The patient was motivated for sustained sobriety.  He had supportive friends and family and safe housing.  He denied any cross-addiction with other substances, while his co-occurring insomnia, hypertension and depressive symptoms did not require service delivery in a venue more restrictive than the outpatient setting.  There was no evidence in the record that the patient had previously engaged chemical dependency treatment services during the episode of illness, such as substance use counseling, anti-craving medication, sober living environments, intensive outpatient programming or partial hospitalization.  This is significant because modern psychiatric practice favors treatment in the community, as outcome measures and therapeutic gains are optimized in this environment.  In sum, the record does not reflect that comprehensive, evidence-based services provided in a less restrictive setting would have been inadequate at the time.  All told, substance abuse residential treatment center services were not medically indicated for the 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 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 for Harvoni for 12 weeks for treatment of her hepatitis C virus (HCV).  Findings:  The physician reviewer found that the proposed treatment regimen of Harvoni for 12 weeks is medically necessary and is considered the standard of care for the treatment of patients with HCV, genotype 1. Per the American Association for the Study of Liver Diseases/Infectious Disease Society of America (AASLD/IDSA) guidelines, all patients with chronic active HCV are eligible for treatment and should be treated with U.S. Food and Drug Administration (FDA) approved antiviral therapy regardless of fibrosis score. Successful hepatitis C treatment results in sustained virologic response (SVR), which is tantamount to virologic cure, and as such, is expected to benefit nearly all chronically infected persons. The evidence supports treatment in all HCV-infected persons, except those with limited life expectancy (less than 12 months) due to nonliver-related comorbid conditions. The goal of treatment of HCV-infected persons is to reduce mortality and liver-related health adverse consequences, including end-stage liver disease and hepatocellular carcinoma, by the achievement of virologic cure. The proposed regimen of Harvoni is consistent with FDA guidelines and is medically necessary to prevent further development and progression of fibrosis due to ongoing HCV infection. Further, since this patient is on a medication which contains fluticasone, Viekira Pak should not be used because of the potential drug-to-drug interaction between fluticasone and ritonavir (one of the agents in Viekira Pak) which has been shown to result in Cushing syndrome. All told, the requested Harvoni for 12 weeks is medically necessary for treatment of the patients hepatitis C virus. 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 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: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested magnetic resonance imaging (MRI) of the thoracic spine and MRI of the lumbar spine for evaluation of the enrollees low back pain. Findings: The physician reviewer found that there is sufficient support for the services at issue in this clinical setting.  This patient was found to have at least 8 degrees scoliosis on x-ray.  The patients provider was concerned that this degree of scoliosis was greater than that of idiopathic etiology.  The provider recommended trial of physical therapy, as the patients neurological status was normal.  The provider also recommended MRI scans of the thoracic and lumbar spine, and these were performed prior to commencement of physical therapy.  Per the current guidelines, the completion of physical therapy is not required first when the patient is a child and the examinations are performed as a combination for scoliosis.  Therefore, MRI of the thoracic spine and MRI of the lumbar spine, both without contrast, were medically indicated for the evaluation of this patient.Final Result: The reviewer determined that the services at issue were 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 diagnostic 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.
Appeal type: Medical Necessity
Decision: Overturned

A 58-year-old female enrollee requested authorization and coverage for gastric bypass surgery for the treatment of obesity. The Health Plan denied the enrollees request indicating that the requested treatment is not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer overturned the health plans denial on the basis that the requested procedure is medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for bilateral breast magnetic resonance imaging (MRI) with and without contrast (CPT 77049). This patient presents with a family history of breast cancer in her mother and maternal grandmother. The patients provider has recommended breast magnetic resonance imaging (MRI), given her family history and findings of microcalcifications in the right breast and two rounded asymmetries in the left breast. The current peer-reviewed medical literature and guidelines recommend biopsy for a palpable breast mass, even in the setting of negative mammogram and ultrasound findings. However, MRI is indicated for the screening of high risk patients. This patient has one first-degree and one second-degree relative with breast cancer, making her high risk for developing breast cancer. The patients lifetime risk as estimated by a genetic counselor is high, which supports an indication for MRI screening as the appropriate modality. Based on these findings, the requested bilateral breast MRI with and without contrast (CPT 77049) is likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Findings:  Two of the three physician reviewers found the requested bilateral breast MRI with and without contrast (CPT 77049) is likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested services are likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewer 1 is board certified in internal medicine with subspecialty certifications in medical oncology and hematology and is actively practicing. Physician reviewer 2 is board certified in internal medicine with subspecialty certification in medical oncology and is actively practicing. Physician reviewer 3 is board certified in medical oncology with subspecialty certification in hematology 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: Overturned

The patient has requested reimbursement and prospective authorization and coverage for Saxenda. Few medications are currently available for the treatment of obesity, and their effectiveness and benefits often fade when the medications are discontinued. Saxenda has demonstrated a statistically significant and clinically meaningful weight loss as an adjunct to a reduced-calorie diet and increased physical activity. Studies have demonstrated that patients using Saxenda can successfully achieve weight-loss benchmarks. This patient has Hashimotos thyroiditis, obesity, and elevated morning serum cortisol. She has failed to lose weight with diet changes and exercise. The addition of Saxenda to her regimen is appropriate given the support in the medical literature.  Final Result: The reviewer determined that the medication at issue was and 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 internal medicine with subspecialty certification in diabetes, endocrinology, 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for digital breast tomosynthesis.Findings:  Two physician reviewers found that the report noted stable findings with no evidence of cancer. This tomographic method often allows the reader to separate dense glandular elements from underlying mass/architectural distortion resulting in a decrease in callbacks and biopsies and an increase in detection of small cancers when compared to two dimensional imaging alone. Breast tomosynthesis provides advantages to radiologists interpreting mammograms.Final Result: Two reviewers have determined that the service at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: All three physician reviewers are board certified in diagnostic radiology 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: Overturned

The parents of a four-year-old female enrollee have requested for speech therapy (ST) and occupational therapy (OT) for treatment of the enrollees articulation disorder. Findings:  Two physician reviewers found that standardized assessment for preschoolers was conducted and the patient was recommended direct, individual occupational therapy (OT) services once a week to be reevaluated in 6 months. The patient is not receiving sensory integration therapy. She has speech delay and needs ST and is the appropriate standard of care. The referral for OT evaluation was also appropriate in light of the speech therapists assessment. Combining OT and ST together is very essential for quicker and effective results. Research studies have shown improvement in well-being and self confidence in children receiving these therapies. Remediation of speech delays in the preschool years is important for kindergarten readiness.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a three-year-old female enrollee has requested speech therapy for treatment of the enrollees autism. Findings:  The physician reviewer found that children with autism typically have deficits in speech and language, as well as social communication. The more aggressively these deficits are targeted, the better chance young children have for developing adequate skills to function in the community. Thus, speech therapy is medically necessary for the management of this patients speech and language delays.
Appeal type: Medical Necessity
Decision: Upheld

A 43-year-old female enrollee has requested Neurostar transcranial magnetic stimulation (TMS) therapy for treatment of her behavioral health conditions. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services in this patients case.  Neurostar TMS therapy has been approved for the treatment of major depressive disorder which has failed to respond to at least one trial of antidepressant medication in the current episode of illness.  It has not been approved for dysthmic disorder or generalized anxiety disorder.  Based upon the clinical notes, this patients condition is not treatment-resistant or refractory to standard therapies.  Per the current medical evidence, psychotherapy is an effective treatment modality for dysthmia.  All told, the requested Neurostar TMS therapy is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 37-year-old male with chronic pain due to fibromyalgia. The patients provider indicates the patient has been tried on many medications but is highly allergic to the time-release ingredient in many medications and also has acetaminophen intolerance. The provider started the patient on a regimen of Subutex and compounded hydrocodone, which he indicates has been very effective. The Health Plan has denied authorization for these medications on the basis that they are not medically necessary.Subutex and compounded hydrocodone are not clinically appropriate for the long-term chronic management of fibromyalgia pain. Although these medications may be utilized for brief periods, their long-term use is not recommended or within the standard of care. Patients with fibromyalgia often benefit from a baseline exercise physical rehabilitation program, which does not appear to have been incorporated in this case. In any event, the long-term use of Subutex and compounded hydrocodone is not clinically indicated or medically warranted. Therefore, I have determined the requested medications are not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An  enrollee has requested reimbursement and prospective authorization and coverage for weekly occupational therapy services for treatment of the enrollees impaired skills in grasp, coordination, and writing. Findings:  The physician reviewer found that the records provided for review indicate that this patients occupational therapy scores were not low enough to support occupational therapy services as medically necessary. The patients deficits are not severe enough to require medical intervention. The patient may be eligible for school based programs to improve her fine motor skills including handwriting. However, the patient does not have a congenital developmental disability to support an indication for occupational therapy. In addition, the patients fine motor delays are not far enough behind her peers to warrant occupational therapy services. Final Result: The reviewer determined that the services at issue were not and 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 pediatrics with sub-specialty certification in developmental and 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

This patient is a 43-year-old male with chronic, severe low back pain, chronic neck pain, and acute episodic pain related to Crohns disease. The patient indicates standard pain medications have not effectively managed his pain and his provider prescribed a quantity of 30 800mg Actiq for an acute Crohns flare in July 2006. Authorization was denied by the Health Plan and the patient paid out of pocket for the prescription. His request for reimbursement and prospective authorization of Actiq was denied by the Health Plan based upon a determination that the medication is not medically necessary.Actiq is currently approved by the FDA for the management of cancer-related breakthrough pain. The medication has not been approved for the management of Crohns disease or chronic neck or back pain. The use of Actiq in this context is not medically indicated and is not consistent with the community standard of care. Therefore, I have determined the requested medication 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 Xyosted. This patients records document low testosterone secondary to testicular hypofunction. He failed to improve with topical testosterone replacement therapy. He demonstrated clinical improvement with Depo-testosterone injection therapy. However, he is unable to tolerate the injections. The patient would prefer the subcutaneous testosterone enanthate autoinjector (SCTE-AI) therapy with Xyosted. Xyosted auto-injectors have been shown to be effective for testosterone replacement therapy and are approved by the U.S. Food and Drug Administration (FDA) for this purpose. One study found that SCTE-AI offers a testosterone delivery system that is a convenient weekly option to treat testosterone deficiency. Medical literature reported that the SCTE-AI device is safe and intuitive to use, with a low potential for harm and is associated with a high rate of injection success, regardless of prior training or experience. Given this patients prior failure with topical creams and sildenafil, the requested Xyosted is medically necessary for the treatment of patients testicular hypofunction.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 urology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the Guardant360 molecular profiling gene test performed. Findings:  The physician reviewer found tha  : Adenocarcinomas of the lung should be evaluated for specific molecular abnormalities, such as EGFR mutation, ALK, and ROS1, which have clear therapeutic implications. Such testing can be done either through tissue sampling or by evaluating cell-free DNA in plasma, such as with the Guardant360 assay. The National Comprehensive Cancer Network (NCCN) recommends consideration of plasma testing if tissue testing is not feasible. There also seems to be a role for plasma testing in patients who were found to have an EGFR mutation, were treated with an EGFR related drug, and show progression. The Guardant360 assay can detect a further EGFR mutation for which there is accepted treatment. However, as best as could be determined from the records submitted in this case, this patient underwent a tissue biopsy which demonstrated that these possible mutations did not exist. Thus, additional testing with the Guardant360 assay would not have provided further diagnostic data beyond that obtained with standard testing. All told, the Guardant360 molecular profiling gene test performed  was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: The reviewers determined that the testing at issue was 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 reviewers 1, 2 & 3 are board certified in internal medicine with sub-specialty certification in medical oncology 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

A male enrollee requested Fentanyl 75 mcg every 72 hours, and Soma 350 mg twice per day for medical treatment of his chronic low back pain with exacerbation secondary to lumbar facet arthropathy and lumbar degenerative disc disease.  Findings:  The physician reviewer found that the current standard of care for chronic pain associated with disc herniation is treatment in a multidisciplinary practice to include physical therapy, massage therapy, cognitive behavioral therapy, and injections to help reduce pain. Chronic opioids and Soma are associated with a high risk of dependence and tolerance and therefore long-term administration is not recommended (Fishman.)   Ballantyne and Mao reported that prolonged use of high dose opiates might induce tolerance, abnormal pain sensitivity, and hormonal effects. All told, the requested Fentanyl 75 mcg every 72 hours, and Soma 350 mg twice per day are not medically necessary for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 45-year-old male enrollee requested authorization and coverage of intradiscal electrothermal therapy (IDET). The Health Plan denied the request indicating that the requested therapy is experimental for treatment of the enrollees back pain.Three physician reviewers performed an experimental/investigational Independent Medical Review. All three physician reviewers concluded that the requested therapy is not likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy. Because all three physician reviewers concluded that the requested therapy 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.