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

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for 30 hours per week of direct applied behavior analysis (ABA) services by a paraprofessional (Code H2019). To determine the medical necessity of ABA, research by Papatola and Lustig provides guidelines. According to the authors, 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. Based on the presenting information, this patient meets the medical necessity criteria for direct ABA services. The requested services are specifically tailored to meet the needs and deficits of this patient. In addition, the National Autism Center has identified ABA as the most effective evidence based treatment for children and adults on the autism spectrum. Thus, the requested services are required to meet the patients essential health needs and is consistent with the patients diagnosis of autism. With regard to treatment intensity, the Behavior Analysis Certification Board (BACB) outlined guidelines, which incorporate the presenting concerns of the patient. Treatment intensity and duration is unique to these presenting concerns and are based on progress and remaining skill deficits. This patients provider has listed over 30 goals in the current treatment plan. Further, the treatment plan outlines discharge criteria, indicating the providers have identified a level of skill acquisition for the patient to no longer require ABA therapy. Overall, the records suggest that these services are not for the patients convenience and are being provided in the least restrictive setting available to deliver appropriate health care. The patient has demonstrated progress, meeting 35 of 49 goals in one authorization period and 7 of 39 goals during the following authorization period. Given this information, 30 hours per week of direct ABA services by a paraprofessional (Code H2019) are medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned
Appeal type: Medical Necessity
Decision: Upheld

A 50-year-old female enrollee requested authorization and coverage of Tri-Luma cream. The Health Plan denied the request indicating that the requested medication is not medically necessary for treatment of the enrollees skin 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 medication is not medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld

A 56-year-old male enrollee has requested a PET scan of the brain for an evaluation of his toxic encephalopathy. Findings:  Two physician reviewers found that the relevant evidence demonstrates that a more basic imaging test, such as an MRI, should have been performed prior to therapy and the PET scan. There is a lack of literature to support the use of PET scan in this clinical setting. PET scan would not have changed this patients diagnosis or potential treatment.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Humira Citrate-Free 40 mg/0.4 ml pen.Humira is effective for the treatment of pouchitis with characteristics of Crohn's disease, and is recommended by guidelines for the treatment of Crohn's disease. The pain associated with citrate in Humira and other medications is associated with negative impact of adherence in patients with inflammatory bowel disease, and the citrate-free formulation of Humira is associated with significantly less injection-site pain. In this case, the patient has a history of ulcerative colitis and is status-post pouch. The patient has a current diagnosis of Crohns disease and has symptoms of active pouchitis. The provider has recommended aggressive treatment that will include Humira, in order to avoid progression of illness. Under these circumstances, the requested Humira Citrate-Free 40 mg/0.4 ml pen is medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested medication is medically necessary to treat the patient's medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in internal medicine, with subspecialty 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 patient has requested authorization and coverage for Ozempic 1 mg. The records provided for review document that this patient has a history of type 2 diabetes complicated by obesity. The patient has started treatment with Ozempic. The patients provider has recommended continued treatment with this medication. Although lifestyle modification is recommended as the cornerstone of obesity management, many patients do not achieve long-lasting benefits due to difficulty with adherence as well as physiological and neurohormonal adaptation of the body in response to weight loss (Gadde, et al.). There are currently multiple pharmacologic therapies which are available for weight management. Ozempic is a member of a class of medications known as glucagon-like peptide-1 (GLP-1) agonists, which have been shown to improve glycemic control, reduce body weight, and decrease cardiovascular risk (Knudsen and Lau). Multiple studies have demonstrated the efficacy of Ozempic in the promotion of weight loss, via reduced appetite and energy intake, and delayed gastric emptying (Cornell). All told, the requested Ozempic 1 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 internal medicine with subspecialty certification 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: Overturned

Nature of Statutory Criteria/Case Summary: The patients parent has requested reimbursement and prospective authorization and coverage for past in-home nursing services, and future in-home nursing services for up to 16 hours per day. Although dated, the Committee on Children with Disabilities continues to guide treatment decisions in the disabled pediatric population. The guidelines noted that the overarching goal of a home health care program for infants, children, or adolescents with chronic conditions is the provision of comprehensivehealth care within a nurturing home environment that maximizes the capabilities of the individual and minimizes the effects of the disabilities. Further, children with special needs frequently require equipment at home to allow for safe and effective care. Such equipment may facilitate feeding and eating, toileting, bathing, safe sleeping, and mobility, as well as offer opportunities to achieve functional skills. This patient has a number of medical issues associated with her genetic condition. Her skilled nursing needs require 24-hour attention to monitor her airway, breathing, positioning, and feeding. During the day, it is reasonable to expect her family to provide for her needs, including the intermittent gastrostomy feedings and medication administration. However, at night, she receives continuous feedings. It is not reasonable to expect the family to continue bedside diligence overnight. Therefore, skilled nursing services were and are medically necessary for 12 hours per night, seven nights per week. Final Result: The reviewer determined that a portion of the services at issue were and are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned. Credentials/Qualifications: The reviewer is board certified in pediatrics with subspecialty certification in pediatric critical care 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 25-year-old male enrollee requested authorization and coverage of Betaseron therapy in combination with his Copaxone therapy. The Heath Plan denied the request indicating that the requested therapy is considered experimental for treatment of the enrollees multiple sclerosis.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.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:   An enrollee has requested Repatha injections for treatment of his medical condition.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication.  This patient has increased coronary risk but no documentation of coronary stenosis or clinical coronary event, such as angina or myocardial infarction.  There is no documentation to support a history of homozygous familial hypercholesterolemia or heterozygous hypercholesterolemia.  Familial hypercholesterolemia usually manifests by a combination of physical exam findings and low-density lipoprotein levels that are at minimum above 180, and usually significantly higher.  This is not documented in the medical records provided.  Repatha is a PCSK9 inhibitor studied in and approved only for patients with heterozygous familial hypercholesterolemia or for patients with documented clinical heart disease who require additional lowering of low-density lipoprotein cholesterol.  This patient does not fit any of those criteria.  PCSK9 inhibitors have not been studied in other patient populations, such as this clinical setting.  The current guidelines that are endorsed by several national organizations do not recommend the use of PCSK9 inhibitors in this primary prevention setting.  Finally, there are other statin medications that have lower side effect profiles and have not been documented to be tried or not tolerated in this patient. Therefore, the requested Repatha injections are not medically indicated 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 internal medicine with sub-specialty certification in cardiovascular disease and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 30-year-old female who is seeking reimbursement for duodenal switch surgery. The patients body mass index (BMI) prior to surgery was 56.2. In addition, the patient has a number of comorbid conditions including hypertension and gastroesophageal reflux disease (GERD). The Health Plan has denied reimbursement for the duodenal switch procedure.The duodenal switch procedure has a track record greater than 15 years. The anticipated complication associated with other malabsorptive procedures (i.e., distal gastric bypass, jejunoileal bypass) has not been encountered with the duodenal switch. At the 2003 American Society of Bariatric Surgeons meeting held in Boston, Massachusetts, scientific papers were presented, which indicated there is growing evidence that protein malnutrition is a much larger problem post gastric bypass than was initially suspected. This is due to patients inability to consume normal meals after the gastric bypass procedure. Furthermore, there is sufficient data to show that duodenal switch has a far more superior long-term outcome when compared to gastric bypass. Therefore, the duodenal switch procedure was medically indicated for treatment of this patients super morbid obesity.Based upon the information set forth above, I have determined that the procedure at issue was medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a five-year-old male born with profound bilateral sensorineural hearing loss. He underwent cochlear implantation to his right ear at the age of 24 months. Testing at this time reveals that he receives no benefit from wearing a hearing aid on the non-implanted ear and the parents wish to have an cochlear implant placed for the right ear. Their request for authorization of the sequential cochlear implant was denied by the Health Plan as not medically necessary.The science of cochlear implantation is changing rapidly with time. The criteria for implantation has progressed so that children are benefiting from implantation at a younger age than was initially thought appropriate. There have been several studies exploring the benefit of wearing hearing amplification (external aid) on the unimplanted ear for patients with unilateral implants. These studies support this method of binaural hearing enhancement only in patients whose unimplanted ear still has some measurable hearing that can be enhanced for improvement of speech reception. It is also quite apparent from these studies that binaural hearing ability is far superior to having only one hearing ear and binaural hearing ability is the functional standard for interaction with the world. Bilateral implantation is now performed with increasing frequency based on this knowledge. More studies have been done with adults than with children, but studies on children have also been favorable. Although it is true that bilateral implantation is somewhat new, it has shown clear benefit for many people.  This patient would benefit greatly from receiving a second cochlear implant and, as such, I have determined the requested device is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Upheld

A 64-year-old male enrollee requested a CardioNet Monitor (real time remote heart monitor, CPT 93228 and 93229) for evaluation of his intermittent dizziness.  Findings:  Three physician reviewers found that the real time remote heart monitoring was not likely to either improve or alter patient outcome. In this clinical setting, the deployment of a standard Holter monitoring for 24-48 hours would have been reasonable and appropriate prior to the services at issue. At this time, there is insufficient support in the medical literature demonstrating immediate recognition and reporting through a call center provided by real-time mobile telemetry services results in improved health outcome compared to standard monitoring techniques. Therefore, the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than other standard therapies.
Appeal type: Medical Necessity
Decision: Overturned

A 57-year-old male enrollee has requested lap band surgery for the treatment of his morbid obesity. Findings:  The physician reviewer found that this patient meets the clinical criteria for bariatric surgical intervention. He has the necessary comorbidities and has failed medical management. The lap band has the advantage of easy reversibility and adjustability in the face of a potentially non-compliant patient with significant medical risks. Lap band is medically appropriate and indicated for this patient.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for bilateral peripheral nerve stimulation (PNS) system (StimRouter). Findings:  The physician reviewer found that  systematic review performed by Deer and colleagues reported level II moderate evidence supporting the safety and efficacy of peripheral nerve stimulation (PNS) for the treatment of neuropathic pain of the shoulder. Common nerves that were targeted included the suprascapular nerve. In this case, the patient has neuropathic pain as a complication of foot and ankle surgery and spinal cord injury. Previous trials of standard of care treatments including medication management with neuromodulator agents, Botox, and physical therapy have been ineffective in improvement pain relief and improving quality of life and functionality. The patient has undergone tibial nerve blocks with effective short-term relief of his foot pain. Currently, the most recent reviews of PNS have shown level II evidence for efficacy in treating neuropathic pain in the lower extremities, as in this patients clinical setting. Based on these findings, the requested bilateral PNS system (StimRouter) is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings: Two of the three physician reviewers found the requested bilateral PNS system (StimRouter) is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested device is 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 reviewer 1 is board certified in anesthesiology with subspecialty certification in pain medicine and is actively practicing. Physician reviewer 2 is board certified in anesthesiology with subspecialty certification in pain medicine and is actively practicing. Physician reviewer 3 is board certified in anesthesiology with subspecialty certification in pain medicine 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

A female with hidradenitis suppurativa. She has been treated by a primary care provider with conservative home management and antibiotics, without resolution of symptoms. She has recurrent boils in axillae, groin, and buttocks. The patient has requested coverage for a referral to a dermatologist. The Health Plan denied the request and reported the requested service was not medically necessary for the treatment of this patient. At issue in this case is whether a referral to a dermatologist is medically necessary for the treatment of the patients medical condition. Hidradenitis suppurativa is a chronic, painful, follicular occlusive disease that affects the axillary, groin, perianal, perineal, genital, and inframammary skin. The clinical course is highly variable, ranging from relatively mild cases to severe cases demonstrating deep abscesses, draining sinuses, and severe rope-like scars. The symptoms caused by hidradenitis suppurativa profoundly affects patients quality of life. Treatment of hidradenitis suppurativa includes home management, oral antibiotics, oral retinoids, biologics and surgical interventions. A specialty consultation may be required when the diagnosis is uncertain, complex. or when the course of care may benefit from additional expertise. In this case, the patient has failed to respond to initial conservative care and oral antibiotics. Additional treatment options include oral retinoids, biologics and surgery, which are outside of the scope of practice of a primary care physician and within the expertise of a dermatologist. Thus, a referral to a dermatologist is medically necessary for treatment of this patients medical condition.Final Result: The reviewer determined that the requested service 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 family practice 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.