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

A 39-year-old female enrollee has requested intensive outpatient program (IOP) treatment for treatment of her behavioral health condition. Findings: The physician reviewer found that despite being a month into treatment, this patient was and is was still quite vulnerable to relapse given her need to shift away from cravings-driven friendships and the subsequent void which has left her feeling lonely and bored. This, coupled with persistent mid-level depressed and anxious moods, worsening cravings, lack of step progress, and lack of sponsorship connections supports her need for continued treatment at the IOP level. In addition this patient met the following American Society of Addiction Medicine (ASAM) IOP continuing level of service criteria : 1) she was experiencing minimal or stable withdrawal; 2) there were no biomedical complications or her condition was stable; 3) she had variable engagement in treatment/recovery; 4) she required a structured program several times per week to promote progress in treatment through the stages of change; 5) the symptoms of her addiction indicated a high-risk for relapse or continued use without close monitoring and support, and; 6) her recovery environment is not supportive, but the patient had adequate coping skills to promote recovery in a structured program several times per week. This patient was and continues to be at a high risk for relapse and in need of continued intensive outpatient program (IOP) therapy. She is at a critical point in her recovery and at a vulnerable juncture. All told, the submitted evidence supports the medical necessity of IOP services for this patient.
Appeal type: Experimental/Investigational
Decision: Overturned

A 50-year-old female enrollee has requested repetitive transcranial magnetic stimulation (rTMS) for treatment of her major depressive disorder.  Findings:  Two physician reviewers found that in this patients case, repetitive transcranial magnetic stimulation was and is likely to be of greater benefit than other treatment options.  The American Psychiatric Association has included transcranial magnetic stimulation as an appropriate acute phase treatment option for patients who do not respond adequately to medication therapy.  This patient has been treated with multiple antidepressants of various mechanisms, as well as augmentation with Seroquel and Abilify, but remains symptomatic.  She has undergone cognitive therapy and psychotherapy and has received psychiatric hospitalization services.  This patient has treatment-resistant depression and is an appropriate candidate for transcranial magnetic stimulation therapy.  Therefore, repetitive transcranial magnetic stimulation was and is likely to be of greater benefit than other alternatives in this clinical setting.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for thermography. The Health Plan has denied this request indicating that the requested services are considered investigational for evaluation of the enrollees breast tissue.Findings:  Breast thermography is also known as infrared imaging of the breast and measures infrared emission from the breast tissue. The examination is based on the premise that abnormal tissue will have more blood flow, increased metabolic activity and therefore emit more infrared activity due to higher temperatures. However, researchers do not support the use of thermography as a screening tool in the detection of breast cancer or as a diagnostic examination. There is a lack of research that has shown the benefit with thermography alone or in addition to mammography. Annual screening mammography/digital breast tomosynthesis are recommended for breast cancer screening in women of average risk. Therefore, in this patients case, thermography is not likely to be of greater benefit in the evaluation of the patients condition than the available standard imaging for the evaluation of this patients breast tissue. Final Result: All three reviewers have determined the requested services are 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 diagnostic radiology 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

A 27-year-old female enrollee has requested residential treatment center services for treatment of her substance use disorder and major depressive disorder.  Findings:  The physician reviewer found that this patient was admitted as a result of a family intervention. She resisted her care to the point of signing out AMA after spending weeks in treatment. She was returned to treatment by her mother and was subsequently enrolled in residential day treatment. During this admission, she did not suffer from severe withdrawal, medical complications or acute psychiatric co-morbidity. Applying the American Society of Addiction Medicine placement criteria, a patient with such a low level of severity in symptoms is typically treated successfully at an outpatient level of care such as intensive outpatient program (IOP) services, with or without buprenorphine assistance. This conclusion is also consistent with the practice guidelines from the American Psychiatric Association, which states that, Individuals should be treated in the least restrictive setting that is likely to prove safe and effective. Given this patients level of function and lack of withdrawal symptoms, medical complications or acute co-morbid conditions, she could have safely and effectively been treated in less restrictive level of care than RTC. As she did not require the intensity and supervision provided in a 24-hour residential treatment facility, participation in an IOP would have likely been medically indicated during the period at issue.
Appeal type: Experimental/Investigational
Decision: Upheld

A 38-year-old male enrollee has requested for a BioniCare Knee Device for treatment of his tricompartmental osteoarthritis. Findings:  Two physician reviewers found that there is no class one data to support the use of the BioniCare Knee Device for the treatment of tricompartmental knee osteoarthritis. More quality outcomes data is needed to support this treatment option, and this device is not currently an accepted modality in this setting.
Appeal type: Medical Necessity
Decision: Upheld

A 55-year-old male enrollee has requested for an X-Stop procedure at the L3-4 and L4-5 for treatment of his lumbar spinal stenosis at the L3-4 and L4-5.    Findings:  The physician reviewer found that the short-term literature of the X-Stop states that it is potentially efficacious and it is safe, but there is nothing to suggest medium to long-term data that is as good as or better than standard surgical treatment options.  As of this time, as with all surgeries, the requested X-Stop procedure has significant risks and benefits and the net benefits of X-Stop do not outweigh the net benefits of treatment with standard orthopedic surgical care.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 64-year-old woman with knee arthritis. She underwent a series of Hyalgan injections in July 2005. A request has been made for authorization for a second series of injections. The Health Plan has denied this request on the basis that the injections at issue are not medically necessary.The patient achieved great pain relief with her first series of injections. She is a surgical candidate with severe arthritis in her knee. She is attempting to postpone surgery as long as possible. A second series of injections is a reasonable treatment option. The first series resulted in significant relief. The patients only other option is total knee replacement. A second series of Hyalgan is appropriate to alleviate pain and postpone surgical intervention. Therefore, I have determined the requested therapy is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

The parent of an 18-year-old female enrollee requested authorization and coverage of an electric wheelchair for the treatment of cerebral palsy and spastic diplegia.  The health plan denied the enrollees request indicating that an electric wheelchair is not medically necessary.  The Plan authorized a self propelled lightweight wheelchair.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer overturned the health plans denial on the basis that the requested equipment is medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested genetic testing for evaluation of her medical condition.  Three physician reviewers found that there is a lack of support for the services at issue in this clinical setting.  The role of thrombophilia in first trimester miscarriage remains unclear.  According to American College of Obstetricians and Gynecologists, although thrombophilias commonly are thought of as causes of early pregnancy loss, only antiphospholipid syndrome consistently has been shown to be significantly associated with early pregnancy loss.  This patient does not have antiphospholipid syndrome based on history and other laboratory tests.  The genetic testing in question has not been shown to be of benefit in patients with first trimester losses.  All told, genetic testing was not likely to have been of greater benefit than other modalities. Final Result: Three reviewers determined that the services at issue were 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 obstetrics and gynecology 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

A 54-year-old male enrollee has requested for post acute skilled physical, occupational, and speech therapies as well as residential care, behavior modification and psychotherapy counseling for treatment following multiple ischemic strokes.  Findings:  The physician reviewer found that from a review of the available records, it appears that the patient has significant functional deficits at one year post-stroke. These outcomes were predictable based upon his status in the early stages post-stroke and in the rehabilitation phases of his illness (Ovbiagele, et al). Further, he has not gained significantly since his discharge from a skilled facility (Kwakkel, et al). At this juncture, the records indicate that he has reached a functional plateau (Heuschmann, et al). The patient continues with neglect of his left side, impulsiveness, and agitation with new information and he is also on a percutaneous endoscopic gastrostomy (PEG) tube. Based on a review of the relevant medical literature, additional gains are not expected or predicted as stroke rehabilitation cannot influence outcome in the absence of continued brain healing. As such, the services at issue have not been demonstrated to be medically necessary in this clinical setting and the denial was therefore appropriate.
Appeal type: Medical Necessity
Decision: Upheld

A male enrollee requested physical therapy, twice per week, for medical treatment of his medical condition.  Findings:  The physician reviewer found that evidence-based medical literature recommends conservative management for plantar fasciitis, which includes relative rest, activity modification, stretching of the plantar fascia, other various exercises, physical therapy, weight loss, insoles, night splints and walking casts.  In this case, the patient has undergone sufficient therapy to be fully independent with a home exercise and modality program for both his plantar fasciitis and his earlier peroneal tendinopathy.  Although the patient remains symptomatic, no significant benefit would be expected with further formal physical therapy over an independent program.  All told, the requested physical therapy, twice per week, is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

An enrollee has requested authorization and coverage for a wheelchair car lift.Weakness in post-polio syndrome, which can develop after many years or decades of stability following an acute poliomyelitis episode, is thought to be the result of ongoing neurological processes, including a reduced number of active motor units and motor unit size diminution, with a failure of reinnervation processes to keep up with and compensate for ongoing denervation processes. This weakness can gradually progress and potentially result in severe functional impairment and poor quality of life. Recommendations in this clinical setting generally include energy conservation techniques, pacing strategies, and generally participating in activities at a judicious level, i.e., avoiding overuse of weak muscles, while also avoiding inappropriate levels of inactivity.In this case, the patient has a weak right leg due to post-polio syndrome. She has been ambulating by compensating with her unaffected leg and upper limbs. This has caused significant strains on the connective tissues of these limbs. She also uses a wheelchair for some mobility. She has requested a wheelchair car lift to transport her wheelchair in her car. Her impairments make it difficult to impossible to get her wheelchair into and out of the vehicle. While travel in a motor vehicle may be desired; however, it is an elective activity, and is not needed to accomplish mobility-related activities of daily living or instrumental activities of daily in a reasonable and timely manner. Accordingly, the requested wheelchair car lift for vehicle transportation is not medically necessary because travel in a motor vehicle is not a medical necessity. Therefore, the requested wheelchair car lift is not medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested equipment 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 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: Upheld

A 42-year-old female enrollee has requested treatment on a monthly basis for her multiple medical conditions. Findings:  The physician reviewer found that the patient has been followed by an out-of-network physician who has recommended treatment consisting of pain medication, trigger point injections and caudal ESIs. Based on the documentation provided, the patient does not meet Medicare or other standard of care guidelines for caudal ESIs. Current standards of care strongly suggest that caudal ESIs have been replaced with fluoroscopically guided transforaminal ESIs in the long-term interventional management of radiculopathy due to spinal pathology, such as herniated discs and/or spinal stenosis. Therefore, the recommended caudal ESIs are not medically necessary at this time. The Health Plans recommendation for an evaluation with an in-network pain management specialist is appropriate for the patient to discuss other treatment options that are consistent with the current standards of care for the treatment of her medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The parent of an enrollee has requested authorization and coverage for Omnitrope. Based on medical literature, the records do not support a diagnosis of GH deficiency. The diagnosis of GH deficiency is supported by a GH stimulation test. The records do not document that the patient has undergone a GH stimulation test with results consistent with GH deficiency. Based on other documents, the patients growth velocity is 7 cm per year, without any GH treatment. This is a normal growth velocity and does not support a pathologic cause for short stature. There is no recent bone age prior to starting GH therapy to estimate the patients adult predicted height. The patients pre-treatment height in July 2019 was -1.85 standard deviations (SDs) below the mean. GH is indicated for idiopathic short statute when a patients height is below -2.25 SDs for age and gender. All told, Omnitrope was not and is not medically necessary for treatment of this patient. Final Result: The reviewer determined that the medication at issue was not and 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 with subspecialty certification in pediatric 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: Overturned

A 67-year-old male enrollee has requested a Tobii ATI DC-DC Converter 24-12v for treatment of his medical condition. Findings:  The physician reviewer found that in order for this patient to effectively communicate during the course of his daily activities, the SGD must be mounted and powered by his power wheelchair. A Tobii ATI DC-DC 24V-12V Converter is required in order to use the wheelchair's battery to power the MyTobii P-10 device. Without the converter kit, the ability of the patient to use the prescribed SGD would be severely restricted. Therefore, the requested equipment is a medically appropriate and necessary component of his overall treatment plan for the treatment of his severe dysarthria.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for GeneSight genetic testing provided by Assurex. In this case, the patient presented to his provider with complaints of mental health decline over the previous few years due to a depressive episode. The patient indicated that his current medication for treatment of bipolar II disorder, panic disorder, generalized anxiety disorder (GAD), and post-traumatic stress disorder (PTSD), was no longer effective. The patients provider recommended GeneSight genetic testing. In the peer-reviewed medical literature, Pardinas and colleagues noted that with regard to GeneSight genetic testing, there is a lack of large-scale replication studies, inconsistencies in defining valid treatment outcomes across experiments, a failure to routinely incorporate adverse drug reactions and serum metabolite monitoring in study designs, and inadequate investment in the longitudinal data collections required to demonstrate clinical utility. The current standard of care does not include genetic testing to assist in therapeutic decision making in the management of patients with mental health disorders including depression, GAD, PTSD, and bipolar disorder. Therefore, the GeneSight genetic testing provided by Assurex was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Findings: Two of the three physician reviewers found that the GeneSight genetic testing provided by Assurex was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewer 1 is board certified in psychiatry and is actively practicing. Physician reviewer 2 is board certified in psychiatry with subspecialty certifications in preventive medicine and brain injury medicine and is actively practicing. Physician reviewer 3 is board certified in psychiatry with subspecialty certification in preventive 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: Experimental/Investigational
Decision: Upheld

A 61-year-old male enrollee has requested for Botox injections for treatment of her chronic headaches. Findings:  Two physician reviewers found that the medical literature does not demonstrate conclusively that Botox is helpful in managing chronic daily headache or episodic type of migraine headache. At this point, there is not sufficient evidence establishing that Botox is expected to provide superior treatment results compared to available standard treatment. There are other preventive medications available for this patients headaches.
Appeal type: Medical Necessity
Decision: Upheld

A 58-year-old female enrollee has requested mole removal for treatment of her mole located on her right eyebrow. Findings:  The physician reviewer found that the patient has a history of seborrheic keratosis and recently reported a mole on her right eyebrow. She declined an appointment for further evaluation of this mole. No clinical details have been provided regarding this growth. If it is confirmed that the growth is a seborrheic keratosis (a benign skin growth) its removal would be considered cosmetic in nature and not medically necessary absent documented evidence of a functional impairment. Based on the documentation provided, there is no information to support the patients mole removal as medically necessary or reconstructive in nature.
Appeal type: Medical Necessity
Decision: Overturned

ature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for an ultralight wheelchair for treatment of the enrollee, who has a history of spastic diplegic cerebral palsy. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested equipment. This patients mobility and subsequently his ability to actively participate in home, school, and community activities are significantly impacted by his medical condition. He uses several pieces of adaptive equipment, but is unable to participate fully due to fatigue and muscle weakness. Per the records, he requires appropriate adaptive equipment to allow for maximum participation in home, school, and community activities. The requested ultralight wheelchair will provide this patient with independence and allow him to participate in activities and optimize his functional potential. Thus, the requested ultralight wheelchair is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested equipment 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 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.