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

The parent of a 16-year-old male enrollee has requested coverage for residential treatment services. The Health Plan has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavioral health issues.  Findings:  The physician reviewer found that based on review of the available records, this is a very complicated patient with problems of every sphere of the bio-psycho-social framework, all of which require treatment in a fully coordinated manner. Although the patient did not reportedly participate in a partial hospitalization program (PHP) or intensive outpatient program (IOP) prior to admission to the RTC, he had already been engaged in a wilderness camp and therapeutic boarding school for more than one year. In addition, the treatment he received at those facilities was far more intensive and of longer duration than would be provided in a PHP or IOP. Moreover, the patients family discord from the divorce and the allegations made against the patients father would have made treatment in the home environment with a PHP or IOP inadequate. In support of the clinical necessity of the RTC services during the period at issue, the provider from the Monarch School documents that the patients progress was limited and not at a high enough level of intensity to meet his needs. Thus, the supervision and direction of the 24-hour RTC level of care was indicated and continued to be appropriate for the duration of his stay. In fact, the records indicate that the patients progress in the RTC, given the chronicity and severity of symptoms, was actually quite remarkable. Since all reasonable lower levels of treatment had been exhausted before the patient was admitted to the RTC level of care, the services provided have been shown to be medically necessary for management of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 62-year-old female enrollee requested authorization and coverage to be treated by an out-of-network Oncologist for the treatment of 4th stage metastic lung cancer.  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 services are 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 Octagam 30 grams daily for 3 days (loading dose) then 75 grams every 3 weeks for 3 cycles. Findings:  The physician reviewer found that standard management of small fiber neuropathy depends on the underlying etiology with concurrent treatment of associated neuropathic pain. Liu and colleagues note that small fiber polyneuropathy has various underlying causes, including associations with systemic autoimmune conditions. The authors further noted that IVIG was safe and effective for the treatment of small-fiber polyneuropathy. In this case, the patient has small fiber polyneuropathy with laboratory evidence of autoimmunity. Given that she has tried and failed conventional medical therapy, her autoimmune small fiber neuropathy may improve clinically with IVIG. Therefore, Octagam 30 grams daily for 3 days (loading dose) then 75 grams every 3 weeks for 3 cycles is likely to be more beneficial for treatment of this patients condition than any available standard therapy.Findings:  Three of the three physician reviewers found the requested Octagam 30 grams daily for 3 days (loading dose) then 75 grams every 3 weeks for 3 cycles 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 medication 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 neurology with sub-specialty certification in vascular neurology and is actively practicing. Physician reviewers 2 and 3 are board certified in neurology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested genetic testing for drug metabolizers and advanced lipoprotein testing for evaluation of her medical condition.   Findings:  Three physician reviewers found that the available medical records do not support a specific indication of the requested laboratory testing for this patient. Further, there is a paucity of peer-reviewed medical literature supporting the utility of drug metabolizer status testing and advanced lipoprotein testing in this clinical setting. Accordingly, the genetic testing for drug metabolizers and advanced lipoprotein testing was not likely to have been more beneficial for evaluation of the patients medical condition than any available standard therapy.  Final Result: Three 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:   All three reviewers are board certified in internal medicine and cardiology 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

The patient has requested authorization and coverage for full body magnetic resonance imaging (MRI). The records do not describe placement of a metal clip during a breast biopsy. The presence of metal foreign bodies is occasionally a contraindication for MRI scanning. Researchers found that the presence of metallic implants in MRI can cause substantial image artifacts, including signal loss, failure of fat suppression, geometric distortion, and bright pile-up artifacts which may cause large resonant frequency changes and failure of many MRI mechanisms. The presence of a metallic foreign body or object may cause serious injury due to movement or dislodgment of the metallic foreign body in the presence of the MRI system. There is no indication for utilizing MRI to detect metal of any type, whether it is a clip or a sensor. MRI is not used to detect the type of sensors or to evaluate the symptoms that this patient suspects. In this case, as the records do not indicate a metal clip was placed during surgery and potential metal foreign bodies may pose a safety risk in an MRI scan, the requested service is not medically indicated. Therefore, a full body MRI is not medically necessary for the evaluation of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for transcranial magnetic stimulation (TMS). The patient has been diagnosed with major depressive disorder, generalized anxiety disorder, obsessive compulsive disorder, and body dysmorphic disorder. The records provided for review document that the patient has undergone trials of at least two antidepressants, although the provider noted concern given the patients statements about medication nonadherence. The patient was referred to an IOP, but he did not follow-up with the program. The documentation suggests that the patient has intermittently participated in individual psychotherapy and he continues to use 1-2 grams of cannabis daily. The records do not demonstrate that the patients major depressive disorder is treatment refractory given that he is not engaged in regular individual psychotherapy with a cognitive behavior therapy (CBT) or dialectical behavior therapy (DBT) approach to enhance his ability to tolerate distress and his issues with frustration. Moreover, the patient denied any significant sobriety from cannabis during which time his major depressive disorder, generalized anxiety disorder, and obsessive compulsive disorder could have been evaluated. For these reasons, the requested TMS 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 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for platelet rich plasma therapy. Findings: Two of the three physician reviewers found that platelet rich plasma therapy was not likely to be more beneficial for treatment of the patients medical condition than any other available standard therapy. While platelet rich plasma (PRP) injections have been popular among professional athletes, the science behind PRP injections remains unconvincing. There is limited reliable clinical evidence to guide the use of PRP injections. Although no major long-term or permanent complications have been reported in these relatively short-term clinical trials, it remains to be seen what the results will be with more widespread application of PRP injections. Long-term benefits of PRP have not been demonstrated yet for the treatment of osteoarthritis. In this case, the patient is being treated for symptomatic right hip osteoarthritis secondary to femoroacetabular impingement. At this time, there is no high quality evidence to support the efficacy of PRP for the treatment of the patients diagnosed condition. There is a lack of evidence to permit conclusions on net health outcomes for the use of PRP under these circumstances without the presence of well-designed and executed randomized controlled trials with adequate follow-up regarding outcomes and potential complications. Thus, the platelet rich plasma therapy provided to the patient was not likely to be more beneficial for treatment of the patients medical condition than any other available standard therapy.Final Result: Two of the three reviewers determined that the services at issue were not likely to be more beneficial for treatment of the patients medical condition than any other available standard therapy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: All three reviewers are board certified in orthopedic surgery 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: Experimental/Investigational
Decision: Overturned

A 35-year-old male enrollee has requested transcranial magnetic stimulation for treatment of his major depressive disorder.  Findings:  Two physician reviewers found that the patient has a history of psychotherapy and medication treatment of several years duration, apparently with little success. The attending physician noted that the only viable options for treatment were ECT and transcranial magnetic stimulation.  The patient underwent a course of treatment with transcranial magnetic stimulation for his depression, with an excellent response reported.  The notes from the attending physician indicate that the patient has been tried on lithium, Abilify and Seroquel.  Thus, the patient has been treated with a mood stabilizer, without benefit. The FDA has approved transcranial magnetic stimulation as a specific treatment for severe depression and gives guidelines for its use.  This patient meets the FDA criteria for treatment with transcranial magnetic stimulation.  In this patients case, ECT was rejected due to the side effects.  Several articles from the literature show that transcranial magnetic stimulation compares favorably with ECT.  Therefore, in this patients case, transcranial magnetic stimulation provided on the date in question was likely to have been more beneficial than alternative treatment options.  Additionally, future transcranial magnetic stimulation therapy is likely to be of greater benefit than other available treatment modalities.
Appeal type: Medical Necessity
Decision: Upheld

A 36-year-old female enrollee has requested emergency services for treatment of her neck and back pain. Findings:  The physician reviewer found that review of the submitted clinical documentation demonstrates the patient was involved in a motor vehicle accident which resulted in significant pain. The records indicate the patient was seen at the specified facility.  The patient continued to have pain the next day and she was evaluated by a chiropractor on that day. She then received chiropractic treatment from the time frame specified.The submitted evidence does not demonstrate the patient met prudent layperson criteria for emergent care during the period specified. The chiropractic treatment at issue was administered over more than a two-week period. The treatment was not immediate in nature. In order for a medical condition to be considered emergent, there must be a reasonable belief that immediate medical attention is required. The patient initially sought treatment on the date indicated on an emergent basis for her injuries.  However, based upon the documentation provided, she was treated and released from the specified facility, which is indicative of the stability of her injuries. The next day she sought evaluation from a chiropractor. While the patient continued to experience pain, she had been prescribed medications for pain management. A prudent layperson in this situation would not have reasonably believed chiropractic treatment was necessary to avoid serious jeopardy, impairment or dysfunction; nor was the treatment administered on an immediate basis. As such, the patients symptoms did not meet prudent layperson criteria for emergency care.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 16-year-old female enrollee has requested adolescent psychiatric partial hospitalization program services for medical treatment of the enrollees behavioral health conditions. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested services.  This patient is negotiating the challenging stage of identity formation with co-occurring depression and anxiety.  She has failed treatment with psychotherapy and pharmacotherapy in the outpatient setting.  She has had difficulty tolerating psychotropic medication.  Further, her symptom complex has recently included self-injurious behavior and suicidal ideation and necessitated psychiatric hospitalization earlier this month.  Finally, the record indicates an element of diagnostic uncertainty with the multitude of diagnoses.  Partial hospital services would be reasonably expected to improve her condition, prevent a more serious episode of illness and assist with diagnostic determination.  The progression of treatment services, from the acute level of care to an intermediate setting such as partial hospitalization, is medically appropriate and consistent with community standards.  In sum, adolescent psychiatric partial hospitalization program services are medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

The patient is requesting authorization and coverage for Vemlidy 25 mg tablets.Findings: Guidelines recommend entecavir and tenofovir for the treatment of chronic hepatitis B. In comparison with tenofovir disoproxil fumarate (Viread), the Vemlidy formulation of tenofovir is effective for hepatitis B, but is associated with fewer incidence of side effects such as osteopenia and renal disease. However, the other guidelines also support the safety and efficacy of entecavir for the treatment of hepatitis B, and entecavir is not associated with these adverse effects. This patient does not have a documented contraindication to entecavir. For these reasons, the request for Vemlidy is not supported as 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 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for computer-assisted surgical navigation (CPT code 20985) provided at Seaside Surgery Center. To date, there is a lack of data documenting improvement in patient outcomes with the use of robotics and navigation during partial or total knee arthroplasty (TKA). Jones and Jerabek note that missing from a review of current literature on the role of computer-assisted surgical navigation in TKA were any conclusive demonstrations of clinical superiority in terms of improved patient-reported outcome measures and/or decreased cumulative revision rates in the long term. Lee and colleagues found no significant differences in clinical or radiological outcomes between computer-navigated TKA and conventional TKA. Kim and colleagues concluded, In this randomized trial, with data presented at a minimum of 14 years of follow-up, we found no benefit to computer navigation in TKA in terms of pain, function, or survivorship. Unless another study at long-term follow-up identifies an advantage to survivorship, pain, and function, we do not recommend the widespread use of computer navigation in TKA because of its risks (in this series, we observed femoral notching; others have observed pin site fractures) and attendant costs. The current scientific evidence does not support the use of computer-assisted navigation as more beneficial for the treatment of knee arthrosis by partial or total arthroplasty than standard arthroplasty without navigation. Therefore, the computer-assisted surgical navigation (CPT code 20985) provided at Seaside Surgery Center was not likely to have been more beneficial for treatment of the patients condition than any available standard therapy.Findings:  Three of the three physician reviewers found the computer-assisted surgical navigation (CPT code 20985) provided at Seaside Surgery Center at issue was not likely to have been more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The 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: Physician reviewers 1, 2, and 3 are board certified in orthopedic surgery 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

A 54-year-old female enrollee has requested Kineret 100mg for treatment of her rheumatoid arthritis.  Findings:  The physician reviewer found that the patients rheumatologist indicates the patient has failed Plaquenil, sulfasalazine, doxycycline, methotrexate, Arava, and is currently failing quinacrine. Furthermore, the rheumatologists position that any TNF inhibitor would pose a greater risk to this patient than Kineret, is well supported in the medical literature. Kineret has long been an FDA approved treatment for rheumatoid arthritis.
Appeal type: Urgent Care
Decision: Overturned

A 36-year-old male enrollee requested post-exposure prophylaxis (PEP) on an emergent basis for medical treatment of his possible HIV exposure.  Findings:  The physician reviewer found that it is recommended that patients with a known exposure to HIV receive PEP as soon as possible, up to 72 hours post exposure. PEP is a time-sensitive treatment and should be administered as soon as is possible. It requires baseline laboratory testing and rapid HIV testing prior to administration. Therefore, a prudent layperson would have sought medical attention because the absence of immediate medical attention could reasonably be expected to result in placing the patients health in serious jeopardy. All told, the patients symptoms would lead a prudent layperson to believe their health to be in imminent danger. In sum, the patients symptoms met prudent layperson criteria for emergency care.
Appeal type: Experimental/Investigational
Decision: Upheld

A 60-year-old male enrollee has requested an anterior cervical discectomy with artificial intervertebral disc replacement for the treatment of his cervical myelopathy and disc herniation at C4-5. Findings:  Two physician reviewers found that although cervical disc replacement surgery with artificial disc prosthesis is a novel approach to management of cervical myelopathy due to a herniated disc, there is currently insufficient peer-reviewed literature reporting on its safety and efficacy long-term. Furthermore, there is no peer-reviewed evidence directly comparing cervical artificial disc replacement surgery to an anterior cervical discectomy and fusion. Anterior cervical discectomy and fusion remain the standard of care for treatment of this patients condition. In addition, considering this patients myelopathy and progressive neurological deficit, anterior cervical discectomy and fusion would be the optimal treatment choice for this patient.