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

A 53-year-old female enrollee requested interlaminar lumbar instrumented fusion (ILIF) procedure for medical treatment of her ruptured L4-5 with radiculopathy.  Findings:  Three physician reviewers found that this patients records do not document any motor, sensory, reflex findings, or accompanying symptoms to warrant a diagnosis of a lumbar radiculopathy (Tarulli and Raynor). Her pain generator has not been identified. A single injection anywhere, without a control does not establish a diagnosis or prove the success of an injection. In addition, the ILIF procedure has not received final FDA approval. Further, there is a paucity of studies showing the long-term safety and effectiveness of this device. Given the lack of scientific data demonstrating equivalent or superior clinical outcomes with use of the ILIF procedure, the requested services are not likely to be more beneficial for treatment of this patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:   An enrollee has requested lumbar medial branch blocks for treatment of his medical condition.  Findings:  The physician reviewer found that there is a lack of support for the requested services in this clinical setting.  In the documentation available for review, the provider does not document a pain diary for medial branch block done previously.   The literature indicates that a diagnostic medial branch block is necessary prior to radiofrequency ablation; specifically using a pain diary for the day to verify when the local anesthetic wore off.  Moreover, the submitted records lack details regarding the radiofrequency ablation procedure also completed.  No rationale was given for a repeat medial branch block that would be necessary after radiofrequency ablation. Therefore, the requested lumbar medial branch blocks are not medically necessary for treatment of the patients medical condition.   Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: The reviewer is board certified in anesthesiology with sub-specialty certification in pain medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A female enrollee requested ketamine infusion therapy for treatment of her complex regional pain syndrome (CRPS).  Findings:  Two physician reviewers found that the records do not document the patient has exhausted available standard treatment options (Yampolsky, et al). In addition, Patil and Anitescu reported that the outpatient setting is a good treatment option for ketamine infusion and the doses recommended in the research is less than the dose this patient received in the outpatient setting. In addition, this patients provider indicated that a higher dose of ketamine was planned for the next infusion. All told, the requested inpatient ketamine infusion is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Experimental/Investigational
Decision: Upheld

A 62-year-old female enrollee has requested genetic testing for evaluation of her breast cancer. Findings:  Two physician reviewers found that from the patients correspondence, it appears that she was interested in knowing whether she was a carrier for breast cancer susceptibility genes such as BRCA1 or BRCA2.  There is a brief notation in the patients clinic progress sheet of her mothers cancer. There is no note from a genetics counselor or from a physician who discussed the MammaPrint test. MammaPrint testing, one of the first gene expression array-based prognosticators, classifies tumors as low-risk or high-risk for breast cancer recurrence. It requires unfixed, frozen tissue for DNA microarray analysis of the 70-gene set. The test result, a binary score (low-risk and high-risk), is then derived through an algorithm based upon gene expression. The MammaPrint is not the appropriate test to look for BRCA mutations. Nor was there any other indication for MammaPrint testing is this particular scenario. All told, the genetic testing performed on the said date was not likely to be superior over other methods of evaluating this patient.
Appeal type: Medical Necessity
Decision: Overturned

A 63-year-old male enrollee requested a positron emission tomography (PET) scan for medical evaluation of his malignant neoplasm of thymus.  Findings:  The physician reviewer found that the submitted documentation and relevant literature demonstrates the medical necessity of the diagnostic study.  The documentation indicates that the patient had CT/PET performed as an initial staging exam and after chemotherapy was completed.   Given that there are prior studies to compare the scan to, the use of this technology is medically necessary for evaluation of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for skilled nursing facility services. Researchers note that while many older adults require skilled nursing care following hospitalization, the overuse of institution-based skilled nursing care may be associated with various adverse medical consequences, and thus the transition of appropriate candidates to community-based living and care should be encouraged. Researchers report that inpatient skilled nursing facility level of care is indicated when a patient has an ongoing medical need for skilled nursing or skilled therapy services. In this case, the patient has multiple chronic conditions, including chronic pain in her left foot and mental health diagnoses. The records note that she is stable with pharmacotherapy. She is noted as independent and capable of living in the community. Given that the records do not demonstrate an ongoing need for skilled nursing services, the services at issue were not and are not medically indicated. Therefore, skilled nursing facility services were not and are not medically necessary for the treatment of this patient.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 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.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for an In-Home Family Treatment (IIFT) program that includes video monitoring in the home setting, individual therapy in the office and home setting, and family therapy (with and without the enrollee) in the home setting.In this case, the patient has diagnoses of oppositional defiant disorder and major depressive disorder. The submitted documentation indicates that the patient has a history of significant anxiety and mood concerns that have contributed towards suicidal ideation and self-harm, which in turn have contributed towards two psychiatric hospitalizations and failed outpatient treatment. The submitted records reflect that the patient had an intake assessment that indicates that the patient is a good candidate for in home family therapy, with treatment goals of improving family relationships and teaching the patient to use emotion regulation and distress tolerance skills to reduce suicidal urges and reduce psychiatric hospitalizations to zero. Records indicate that less intensive behavioral interventions such as outpatient individual therapy, outpatient psychiatric care, and outpatient dialectical behavior therapy have been unsuccessful in reducing or eliminating the patients problem behaviors. In addition, clinical evaluation suggests that the patients clinical condition would benefit from the requested in home family therapy, which is designed specifically for complex children and adolescents to stabilize them in the home. Accordingly, the requested In-Home Family Treatment (IIFT) program including 24-hour video monitoring in the home setting and utilization of clips of negative interactions for therapeutic and family therapy purposes, one hour per week of individual therapy in the office setting (code 90837), one hour per week of individual therapy in the home setting (code 90837), one hour per week of family therapy with the patient present in the home setting (code 90847), and one hour per week of family therapy without the patient present in the home setting (code 90846), for approximately 6 to 9 months with a reduction in hours as the patients condition improves, is medically necessary to treat the patients condition.Final Result: The reviewer determined that the requested services are medically necessary to treat the patient's condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in psychiatry, with subspecialty certification in child and adolescent psychiatry, and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Synthroid for treatment of her Hashimotos thyroiditis. The physician reviewer found that the American Thyroid Association (ATA) guidelines state that changes between levothyroxine products could potentially result in variations in the administered dose and should generally be avoided for that reason. The ATA also noted that it is recommended that once the therapeutic target is reached, the patient should remain on the same dose and preparation of medication to the extent possible. Carswell and colleagues reported that studies suggest that different levothyroxine preparations are not bioequivalent in congenital hypothyroidism. In this case, the patients clinical history includes treatment with generic levothyroxine in the past with poor results. The patient was then changed to Synthroid brand and has done well for many years. A switch back to a preparation to which the patient responded poorly is not consistent with proper medical practice. Thus, the patient should continue with Synthroid brand as she has been treated with this preparation successfully. Consistent with these findings, Synthroid was and is medically necessary for treatment of this patients Hashimotos thyroiditis. 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 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 64-year-old female enrollee requested authorization and coverage for a blepharoplasty to remove excess tissue of the upper eyelid causing functional visual impairment.  The health plan has denied this request indicating that the requested procedure is not medically necessary for treatment of the enrollees medical condition.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer upheld the health plans denial on the basis that the requested referral is not medically necessary.
Appeal type: Urgent Care
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for transportation. This patient has a history of complex congenital heart disease and presented with a febrile illness due to infection with concern for possible cardiac involvement. In this circumstance, transfer to a center with experience in complex congenital heart disease is medically necessary to properly evaluate and treat for potential coexisting cardiac conditions, including endocarditis. Since an active infection was present, this treatment could not have been safely delayed and constituted a medical emergency. The patients complex congenital heart disease could not have been safely and effectively managed at a facility without physicians trained in and experience with adult congenital heart disease. Therefore, transportation was necessary for treatment of an emergency medical condition. Thus, the patient received emergency medical services.Final Result: The reviewer determined that the patient received emergency medical services on the date of service at issue. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer 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: Experimental/Investigational
Decision: Upheld

A 61-year-old male enrollee has requested for radiofrequency tissue shrinkage of the soft palate, base of tongue and floor of the mouth for treatment of his symptomatic obstructive sleep apnea.   Findings:  Two physician reviewers found that the relevant medical literature currently does not include any evidence-based outcome studies demonstrating that radiofrequency of the tongue base, soft palate and floor of the mouth is better than medical devices and nasal CPAP. Furthermore, based on the limited descriptions in the medical documentation, the need for surgical intervention with radiofrequency ablation has not been established in this case. An adequate trial of alternative devices is likely to be more successful for this patient.
Appeal type: Medical Necessity
Decision: Overturned

A 19-year-old female enrollee has requested acute inpatient psychiatric treatment for the treatment of her behavioral health problems. Findings:  The physician reviewer found that during her stay, several psychotropic medication adjustments were required. The overall medical documentation supports the level of care provided. The patient remained at risk for self harm, she was also highly anxious with nightmares and insomnia. The services provided are consistent with the recommendations of the American Psychiatric Association (APA), the level of care guidelines published by the American Academy of Child and Adolescent Psychiatry (AACAP) and the Association of Community Psychiatrists.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a nine-year-old female enrollee requested dyadic developmental psychotherapy for treatment of the enrollees reactive attachment disorder.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  There are a multitude of approaches used to treat reactive attachment disorder.  The current medical evidence does not support the necessity of dyadic developmental psychotherapy as opposed to other available treatment approaches.  While this patient needs treatment for reactive attachment disorder, the specific treatment of dyadic developmental psychotherapy is not medically necessary.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested bilateral breast tomosynthesis for evaluation of the enrollees breast cancer screening.  Findings: Two physician reviewers found that tomosynthesis is a technique that was developed as a problem solving adjunct to routine mammography. In this case, the presence of a breast lump requires optimal imaging to avoid a biopsy. Tomosynthesis has been shown to be better in assessing malignant versus benign findings. The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor. In addition, an ultrasonography is often necessary to better confirm the cystic nature of a mass. For the reasons provided, the bilateral breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: Two reviewers determined that the diagnostic procedure 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: Medical Necessity
Decision: Overturned

The patient has requested reimbursement and prospective authorization and coverage for partial hospitalization program (PHP) 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. Using LOCUS, providers score patients on a scale of 1-5 using a six-pronged Dimensional Rating System. Applying LOCUS, the patient was at some risk for harm as evidenced by passive suicidal ideation over the past month prior to admission. The records also document that prior to admission, the patient was placing herself in risky sexual situations. The patient demonstrated serious functional impairment with significant withdrawal and avoidance of social interactions, disrupted sleep and fatigue due to her intrusive thoughts. The patient had major comorbidities including syncope, which was worsened by her anxiety and obsessive-compulsive disorder (OCD) symptoms. The patients recovery environment was moderately stressful as her OCD symptoms, anxiety and depression caused significant discord in family and other relationships. The patients recovery environment was highly supportive and her parents were involved in her treatment. The patient showed limited response to treatment as previous treatment exposures have been marked least partial recovery for moderate lengths of time with the help of strong professional supports. The patient demonstrated limited engagement as she related to her provider that she established few, if any trusting relationships. This gives the patient a composite score which is consistent with Level 4, medically monitored community based services, such as PHP level of care. Further, PHP services were appropriate for this patient given her frequent panic attacks, disabling OCD symptoms and depression. Given these findings, the PHP services were 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: Medical Necessity
Decision: Upheld

The parent of an eight-year-old male enrollee has requested biomedical treatment, chiropractic neurologist treatment, occupational therapy, speech therapy, music therapy and relationship development intervention (RDI) for the treatment of the enrollees autism. Findings:  Three physician reviewers found that Autism, at this time, has no proven etiology or cure and early intervention is important. Biomedical Therapy:As for biochemical treatment, much of this intervention is based upon unproven theories regarding autistic childrens immunologic and allergic deficiencies. The effects of biomedical interventions are unproven. Therefore, biomedical treatment is not medically necessary to address the patients food sensitivities and autoimmune issuesChiropractic Neurological Therapy:There is a lack of medical studies supporting the clinical effectiveness of chiropractic manipulations in treating stereotypes commonly seen in autistic children. Given the absence of peer-reviewed evidence supporting the efficacy of such therapy, chiropractic neurologist treatment is not medically necessary to address the patients stereotypes (repetitive hand movements).Speech and Occupational Therapy:This patient is currently receiving speech therapy and occupational therapy. The extent of the patients current deficits is not documented in the submitted information. In this patients case, a current evaluation is needed in order to establish the medical necessity of speech and occupational therapy.  Music Therapy:Music therapy has not been sufficiently studied and only has anecdotal supportive evidence. Music therapy is not considered to be a health care service in the treatment of autism spectrum disorders. As such, there is inadequate evidence to support its use as a medically necessary intervention in this setting. RDI:Relationship development intervention (RDI) is not considered to be a health care service for the treatment of autism. It has unknown effectiveness in this setting. There is inadequate data demonstrating its efficacy to support its use in this case.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested placement in an acute inpatient rehabilitation facility for treatment of her medical condition. Findings: The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  This patient has a mobility deficit that is adequately ameliorated by an assistive device.  She does not show a need for occupational therapy or speech therapy.  She has a continued need for physical therapy, but at an outpatient or skilled nursing facility level of care.  The medical records do not document an indication for intensive multidisciplinary therapies in an acute rehabilitation facility.  All told, the requested placement in an acute inpatient rehabilitation facility is not medically indicated for the treatment of this patient.Final Result: The reviewer determined that the requested services 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 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.