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

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for residential treatment center services. The American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists Child and Adolescent Level of Care Utilization System (CALOCUS) provides a reliable framework for determining the appropriate level of care for adolescents needing mental health treatment. Using CALOCUS, treaters score patients on a scale of 1-5 using a six-pronged Dimensional Rating System. The six dimensions include: (1) risk of harm; (2) functional status; (3) medical, addictive and psychiatric comorbidity; (4) recovery environment (a. stressors and b. supports); (5) treatment and recovery history; and (6) engagement. The composite score is then used to determine the level of care needed. Per CALOCUS, residential treatment center level of care requires a composite score of at least 23.Regarding the six CALOCUS dimensions, the patient has some risk of self-harm, given his continuing intent to use substances (score = 2). Regarding functional status, he has minimal impairment (score = 1). There are no comorbidities noted (score = 1). The patient has moderate stress in the home environment for recovery (score = 3); regarding supports, the patients surviving parent is noted to be involved in his treatment (score = 2). The patient is equivocal in his acceptance and commitment to treatment, and he avoids the issues around the death of one parent and will not commit to sobriety (score = 3). The patient is obstructive toward his therapy goals, avoiding issues around the death of one parent and persisting in denial about his use of substances (score = 3); the patients surviving parent generally accepts treatment, but is reluctant to have the patient home again (score = 2). For a CALOCUS composite score of 17, the recommended level of care is high-intensity outpatient therapy. Therefore, residential treatment center services are not medically necessary for 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 psychiatry and specializes 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 the brand name medication Synthroid for the treatment of her hypothyroidism.   The physician reviewer found that Levothyroxine is the standard of care for treating hypothyroidism.  However, in this patients case, levothyroxine has caused an adverse event.  Therefore, the requested brand name medication Synthroid is medically necessary in this clinical setting.  Levothyroxine is designated as a drug with a narrow therapeutic index (NTI).  Slight increases or decreases in serum thyroid stimulating hormone (TSH) levels can potentially result in adverse effects due to toxicity or lack of efficacy.  Because there are numerous manufacturers of generic levothyroxine and the preparation varies among the generic equivalents, it is more difficult to maintain steady therapeutic levels on the generic levothyroxine than on the branded medication.  All told, the requested brand name medication Synthroid is medically indicated for the treatment of this patient. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in endocrinology 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 33-year-old female enrollee requested authorization and coverage of repeat gastric bypass surgery. The Health Plan has denied the request indicating that the requested procedure is not medically necessary for treatment of the enrollees morbid 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: Medical Necessity
Decision: Overturned

A 29-year-old female enrollee requested authorization and coverage of group therapy. The Health Plan denied the request indicating that the requested therapy is not medically necessary for treatment of the enrollees depression.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plans denial on the basis that the requested therapy is medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

Findings:  The physician reviewer found that An enrollee has requested authorization and coverage for tissue transfer (CPT 14021) along with the approved panniculectomy (CPT 15830). In this patients case, the records document a large overhanging abdominal pannus with associated symptoms due to skin on skin overlap. The documentation supports that a panniculectomy would be indicated as a functional procedure. This has been authorized by the Health Plan. However, the records do not support the medical necessity of the requested adjacent tissue transfer (CPT 14021). It is unclear which anatomic area will be treated with the adjacent tissue transfer, as the panniculectomy would address the significant overhang. Thus, the medical necessity of the requested services has not been established. In this patients case, the medical documentation does not support that there is an abnormal structure of the body that would be addressed with adjacent tissue transfer. Per the records, it is unclear which anatomic area will be treated with the adjacent tissue transfer. Additionally, the requested services are not likely to improve function or create a normal appearance to the extent possible. The functional component and creation of a normal appearance is associated with the panniculectomy and not with the adjacent tissue transfer. There is insufficient evidence that an adjacent tissue transfer would provide more than a minimal improvement. Therefore, the requested adjacent tissue transfer (CPT 14021) is not reconstructive in nature. Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition and are not reconstructive in nature. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in plastic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested the peripheral bone density test for evaluation of her osteoporosis.  Two physician reviewers found that peripheral bone density of forearm CPT code 77081 is recommended when the spine or hip cannot be measured accurately for any reason. In this case, the patient had no indication for peripheral bone density as the spine and hip measurements were adequate. The measurements of hip and spine were reliable and sufficient to make an assessment and recommendations. Thus, the addition of the peripheral bone density test was not likely to be more beneficial for evaluation of the patients medical condition than standard DEXA without a peripheral bone density test.  Final Result: Two reviewers determined that the services at issue were 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: All three reviewers are board certified in internal medicine with sub-specialty certification in endocrinology and metabolism 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

Nature of Statutory Criteria/Case Summary: The parent of a patient has requested authorization and coverage for Eucrisa 2% ointment for treatment of the enrollees eczema.  Findings:  The physician reviewer found that the Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the patients eczema. The submitted documentation does not support the medical necessity of the requested medication. Eucrisa is an inhibitor of phosphodiesterase 4, a novel non-steroidal treatment for children over the age of two years. It can be applied to any part of the body. without concern for side effects.  It is intended for treatment of mild to moderate eczema. Per the Health Plan, coverage for Eucrisa 2.0% ointment requires failure of other topical immunosuppressive agents for mild to moderate atopic dermatitis in a non-immunocompromised patient. Coverage also requires documentation that corticosteroids are inadvisable due to location or inadequate response. The other possible immunosuppressive agents includes Elidel, and tacrolimus. In this patients case, there is no documentation of use/failure of other immunosuppressant topical medications. The degree of eczema was also not documented. The medical necessity of the requested medication has not been established. Therefore, Eucrisa 2% ointment is not medically necessary for the treatment of this patient.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 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: Overturned

The patients parent has requested authorization and coverage for Xifaxan (rifaximin) 550 mg. SIBO is a recognized cause of gastrointestinal distress and a contributing factor of irritable bowel syndrome (IBS). Although SIBO is typically treated with antibiotics, there are not any U.S. Food and Drug Administration (FDA) antibiotics specifically approved for this indication. Rifaximin, which has been FDA approved for treatment of inflammatory bowel syndrome, has been found to be most effective in treatment of SIBO in adults. The data are more limited in children. However, non-controlled prospective data does support the effectiveness of Xifaxan in the treatment of SIBO in children and adolescents. Medical literature concluded that, these results indicate that antibiotics are an effective means of treating SIBO in children and, although non-rifaximin antibiotics appear to produce greater resolution, the data is weaker for such medications and rifaximin has demonstrated safety in a greater number of participants and studies. All told, the requested Xifaxan (rifaximin) 550 mg is medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in pediatrics with subspecialty certification in pediatric 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: An enrollee has requested authorization and coverage for genetic testing (HHT panel) for evaluation of the enrollees capillary malformation arteriovenous malformation (CM-AVM). Findings:  The physician reviewer found that HHT is a genetic disease that causes multiple arteriovenous malformations in various organs. Common presentations include epistaxis, mucocutaneous arteriovenous malformations, and/or gastrointestinal bleeding. The genetic testing as recommended by this patients provider is for diagnostic purposes. The panel chose is appropriate and focused. In considering the specific of this patients clinical situation, the requested genetic testing (HHT panel) is reasonable and medically necessary for evaluation of this patients medical condition. Final Result: The reviewer determined that the requested testing 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 medical oncology 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 28-year-old male enrollee has requested Percocet 10/325mg (8 per day) and Soma (3 per day) for treatment of his pain. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medications in this patients case.  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.  Short release/acting medications with a high risk of dependence and tolerance such as Percocet and Soma are not recommended.  The current medical evidence does not support the requested medications in this clinical setting.  Ballantyne and Mao noted that prolonged use of short-acting, high-dose opiates may result in abnormal pain sensitivity.  In this patients case, Percocet 10/325mg (8 per day) and Soma (3 per day), alone or in combination, are not medically indicated.
Appeal type: Medical Necessity
Decision: Upheld

A 42-year-old male enrollee requested authorization and coverage of surgical repair of palate, pharynx, uvula, and removal of tonsils for treatment of sleep depravation from snoring.  The health plan denied the enrollees request indicating that the requested procedures are not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer upheld the health plans denial on the basis that the requested procedures are not medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld

A 56-year-old male enrollee has requested a standing magnetic resonance imaging (MRI) scan of the spine for an evaluation of his medical condition. Findings:  Two physician reviewers found that the submitted clinical evidence demonstrates that there is not an established and predictable benefit for a standing MRI in this setting. The relevant literature documents that the spine is a dynamic functional structure and that the relationship between the spinal canal and nerve roots does change with weight-bearing and changes of position. A supine MRI is a standard assessment method. Because the anatomical findings in an upright or positional MRI with weight-bearing are so variable, it is unlikely that the findings can be systematically applied in a clinical setting. Standardizations of technique are important so that clinical criteria can also be standardized. Review of the literature does not demonstrate that this level of standardization has yet been achieved in positional or upright MRIs. Until there is careful standardizations of the technique of obtaining the anatomical study and the diagnostic criteria to be applied in analyzing the images obtained, upright and weight-bearing MRIs have the potential of leading to incorrect clinical diagnoses and unsuccessful interventions.
Appeal type: Medical Necessity
Decision: Upheld

The mother of a 12-year-old male enrollee  requested authorization and coverage of continued speech therapy for the treatment of the enrollees cri-du-chat syndrome. 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 upheld the health plans denial on the basis that the requested therapy is not medically necessary for treatment of the patients medical condition. _______________________________________.
Appeal type: Medical Necessity
Decision: Overturned

The mother of a six-year-old male enrollee has requested growth hormone therapy for the treatment of the enrollees short stature. Findings:  The physician reviewer found that the patient will not achieve a normal adult height without growth hormone therapy.  There is about a 10% incidence of children with IUGR who fail to show catch-up growth by age two years.  The medical literature is replete with references documenting the benefits of growth hormone therapy in such children.  Based upon this patients history and current condition, growth hormone therapy is considered standard of care.
Appeal type: Experimental/Investigational
Decision: Overturned

An male enrollee has requested reimbursement for the genotype DNA/RNA hepatitis C virus testing (CPT 87902) for evaluation of the enrollees pneumonia and chronic hepatitis C virus.  Findings:  The physician reviewers found that In 2012, the Centers for Disease Control and Prevention (CDC) expanded its guidelines originally issued for risk-based hepatitis C virus testing with a recommendation to offer a one-time hepatitis C virus test to all patients born from 1945 through 1965. This recommendation was supported by evidence demonstrating that a risk-based strategy alone failed to identify more than 50% of hepatitis C virus infections in part due to patient underreporting of their risk and provider limitations in ascertaining risk-factor information. Once hepatitis C virus is identified in an individual patient, the American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) guidelines strongly recommend testing based on CDC recommended testing algorithm. Testing should include quantitative hepatitis C virus RNA testing prior to the initiation of antiviral therapy to document the baseline level of viremia, and genotyping to guide selection of the most appropriate antiviral regimen. Final Result: All three reviewers determined that the testing 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: Physician reviewers number one, two, and three are board certified in internal medicine with sub-specialty certification in gastroenterology and 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

A 62-year-old female enrollee has requested reimbursement for BRCA 1 and BRCA 2 genetic testing. The Health Plan has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees risk for breast cancer. Findings:  Three physician reviewers found that there were no clinical signs or symptoms, or a family history suggestive of hereditary breast cancer predisposition to support BRCA 1 and BRCA 2 genetic testing as likely to have been more beneficial for evaluation of this patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient is diagnosed with major depressive disorder. The patient failed treatment with escitalopram, fluoxetine, and duloxetine. The patient was also treated with lamotrigine, Adderall, and armodafinil. The provider noted the patient is an ultra-rapid metabolizer and requires a higher dose of medication for efficacy. At issue in this case is whether Viibryd 40mg is medically necessary for the treatment of the patients medical condition. Viibryd is an effective antidepressant for the treatment of major depressive disorder. The records provided for review document that this patient has been stable on Viibryd 40mg. Prior treatment has included escitalopram, fluoxetine, duloxetine, lamotrigine, Adderall, and armodafinil. Further, he does not have any contraindications for treatment with Viibryd. The medical evidence supports treatment with Viibryd, at the requested dose, in this clinical setting. Therefore, Viibryd 40mg is medically necessary for the treatment of this patients major depressive disorder.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 psychiatry and geriatric 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 authorization and coverage for nasal revision surgery proposed by the provider. Findings:  The physician reviewer found that records provided for review document that this patient has a history of previous nasal operations as well as previous trauma. On physical examination, the provider noted that the patients nasal airway shows some narrowing and there is evidence of an external deviation. The provider has recommended revision surgery. However, with each subsequent surgery, the patients risk of failure is elevated due to an increase in scarring (Howard and Clark; Kocak and Duzenli). Given the patients presentation and prior surgical history, the risks of a revisional surgical procedure outweigh the potential benefits. All told, the revision surgery proposed by the provider is not medically necessary for 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 otolaryngology 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.