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

The patient has requested reimbursement for residential treatment center (RTC) services. Per the American Society of Addiction Medicine (ASAM) criteria, this patient met Level 3.5 criteria for clinically managed high intensity residential services. ASAM criteria focuses on six dimensions to determine the appropriate level of care, which includes: (1) intoxication and withdrawal potential; (2) biomedical conditions; (3) emotional, behavioral and cognitive conditions; (4) readiness to change; (5) relapse, continued use, or continued problem potential; and (6) recovery environment. Based on the assessment, RTC level of case services were medically necessary. Further, Level 3.5 programs are designed to serve patients with specific functional limitations that need safe and stable living environments to develop sufficient recovery skills so they do not relapse. The duration of treatment depends on an individual patients progress in acquiring basic living skills and adequate coping and recovery skills. This patient required treatment through discharge to develop these skills to avoid relapse upon transfer to a less restrictive setting. Given these findings, the RTC services provided were medically necessary for treatment of this patient. Final Result: The reviewer determined that the services at issue were 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 with expertise in addiction medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 13-year-old female who has been diagnosed with dyslexia. The patient has been evaluated by a speech therapist as well as through a reading program. The patient was found to have deficits in reading including symbol imagery, passage decoding, and spelling. These difficulties are affecting the patients writing mechanics. The patients family has requested authorization and coverage for continued speech therapy. The Health Plan has denied the request on the basis that continued speech therapy is not medically necessary.While dyslexia has been well documented as a specific learning disorder, it has not been well established in the medical literature as a condition that can be treated medically. Although speech therapy programs and reading programs have been shown to be of some benefit in this situation the goals of the programs are educational in nature rather than medically based. Thus, there is insufficient evidence that speech therapy is medically indicated for treatment of the patients dyslexia.Based upon the information set forth above, I have determined that the requested therapy is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the digital breast tomosynthesis performed on 11/18/16. The Health Plan has denied this request indicating that for evaluation of her risk for breast cancer. Findings:  The physician reviewer found that tomosynthesis was approved by the U.S. Food and Drug Administration (FDA) for clinical use in 2011. Despite the lack of long-term studies proving an increased survival rate when tomosynthesis has been used as part of screening mammography, the American College of Radiology (ACR) urged the technique be removed from the investigational category in 2014 due to the advantages this new tomographic technique brings to radiologists interpreting mammograms. This technique often allows radiologists to separate dense glandular elements from underlying masses and architectural distortion resulting in a decrease in callbacks and increased detection of small cancers. Thus, the addition of tomosynthesis to the usual two-dimensional protocol was likely of greater benefit to this patient than had her exam been done with two-dimensional imaging alone. Final Result: The reviewers determined that the service 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: Reviewers 1, 2, and 3 are board certified in diagnostic radiology 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

The patient is a 64-year-old man who is requesting authorization and coverage for Viagra. He has used Viagra in the past with reported success. The patient has been taking several drugs for arthritis, but none of these have a known negative effect on erectile function. The Health Plan has denied authorization for Viagra on the basis that it is not medically necessary for treatment of the patients condition.Viagra is an accepted primary therapy for erectile dysfunction. Treatment of erectile dysfunction is goal directed. Whatever treatment is successful and acceptable to the patient and his partner is appropriate therapy. It is estimated that 50% of males over the age of 60 have erectile dysfunction. This is thought to be due to early atherosclerotic changes that develop in the small arterioles before lesions are demonstrated in the larger vessels, which are easier to document. Those who are partially impaired are likely to have an excellent clinical response with Viagra or one of the other, newer 5-phosphodiesterase inhibitors. In fact, the submitted documentation indicates the patient has used Viagra in the past with benefit. Therefore, I have determined that the requested medication is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Upheld

A 47-year-old female enrollee has requested authorization and coverage for transcranial magnetic stimulation (TMS) for treatment of the enrollees depression.  Findings:  Two physician reviewers found that the patient has a history of depression dating back to childhood. Her psychiatric diagnosis is major depressive disorder. The symptom complex consists of sad mood, anxiety, sleep problems, feelings of worthlessness, hopelessness and guilt, irritability, interpersonal withdrawal, and anhedonia. In terms of past psychiatric treatments, the patient has been treated with psychotherapy and completed partial hospitalization. She has not reportedly pursued electroconvulsive therapy (ECT) or required inpatient psychiatric care or residential programming. The patient has trialed multiple psychotropic medications including escitalopram, sertraline, paroxetine, bupropion, venlafaxine, mirtazapine, trazodone, amitriptyline, Nortriptyline, aripiprazole, quetiapine, olanzapine, topiramate, lithium, valproic acid, carbamazepine, modafinil, stimulant medications, and multiple benzodiazepines. Due to persistent symptomatology, the patient was referred for transcranial magnetic stimulation (TMS) evaluation and the therapy was recommended. The Health Plan has denied the patients request for coverage stating that TMS is investigational. Although this fairly new treatment technology lacks a robust evidence base at this stage of implementation, the literature supporting TMS in terms of volume, quality and range of investigation continues to grow. Schutter and Gross suggest that the efficacy of TMS may be greater than originally reported, while George and Demitrack provided more conclusive findings in well-developed studies. In addition, the FDA approved TMS in 2008 based on the available data and the American Psychiatric Association (APA) endorses TMS for the acute phase treatment of major depressive disorder. However, TMS is unlikely to be more beneficial than available therapies in treating this patients medical condition. The peer-reviewed medical literature has mixed reports on patient outcomes when comparing ECT and TMS. All told, ECT remains the proven non-pharmacologic intervention that is considered standard of care in patients with treatment resistant depressive disorder. Currently, there are no well-designed studies that support TMS as superior to ECT. Further, the patients psychiatric evaluation mentions possible influence of personality and interpersonal/situational issues on the patients symptom complex. Finally, there is the presence of significant anxiety and chronicity of symptoms despite treatment interventions. TMS has better results in the absence of co-occurring anxiety and for patients with lesser degrees of treatment resistance. Considering these factors and based on the documentation provided, the requested TMS therapy is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for facial laser hair removal. The Health Plan has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees gender dysphoria and are not reconstructive in nature. Findings: The requested services are medically necessary for treatment of the patients medical condition in this clinical setting. Facial laser hair removal is within accepted standards of practice and clinically appropriate for treatment of gender dysphoria. The patient was born with genetics to grow terminal hair on the face. Excessive facial hair in a female would be considered abnormal and is referred to as hirsutism. Hirsutism is a medical diagnosis where terminal hair grows in female in areas that are normally found in males. This would include the face and parts of the genitalia. A female would be expected to have terminal hair in the scalp, axilla and on the arms and legs. This patients excessive facial hair is more consistent with the male gender. Additionally, hormone therapy has not been effective in improving this patients medical condition. Therefore, facial laser hair removal is medically necessary for the treatment of this patients gender dysphoria.With regards to whether the requested services are considered reconstructive in nature, excessive facial hair in a female is considered an abnormal body structure. It would be abnormal for a female to have terminal hair on the face. The patients abnormal appearance is the result of gender dysphoria, a disease classified in the Diagnostic and Statistical Manual of Mental Disorders. Facial laser hair removal can provide a substantial improvement in the appearance of terminal hair and create a normal appearance to the extent possible. Facial laser hair removal would also provide more than a minimal improvement in the appearance of this patient. For these reasons, facial laser hair removal is reconstructive in nature. 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.Credentials/Qualifications: The reviewer is board certified in dermatology 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

The parent of a five-year-old male enrollee has requested integrative medicine/therapy for treatment of the enrollees autism and severe global developmental delays.  Findings:  Three physician reviewers found the submitted documentation and relevant peer-reviewed literature fails to support the use of the integrative medicine/therapy in this clinical setting. The record indicates that the patients integrative treatment includes diet, medications and supplements. Although the use of complementary and alternative medical therapies (CAM) treatments is prevalent in the autistic population, there is a lack of randomized clinical trials in the medical literature supporting these modalities. At this time, there is inadequate evidence demonstrating that these therapies result in definitive benefit. In the absence of confirmatory evidence of efficacy, the services at issue were not and are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Experimental/Investigational
Decision: Overturned

A 56-year-old female enrollee has requested transcranial magnetic stimulation (TMS) therapy for treatment of her depression. Findings:  Two physician reviewers found that this patient presents with treatment-resistant depression, and she has not responded to multiple medication trials or electroconvulsive therapy. TMS therapy is FDA approved for the treatment of patients with major depression who have failed to respond to psychopharmacologic agents. Additionally, the literature supports the benefits and efficacy of TMS therapy. A study by OReardon and colleagues looked at whether TMS over the left dorsolateral prefrontal cortex is safe and effective for the treatment of major depression. The results showed TMS was significantly superior to sham TMS on all depression scales measured (MADRS, HAMD17 and HAMD24). Response rates were significantly higher with TMS on all three scales at weeks 4 and 6. Active TMS was well tolerated with a low dropout rate for adverse events (4.5%) that were generally mild and limited to transient scalp discomfort or pain. The study concludes that TMS is effective in treating major depression and is associated with minimal side effects. All told, TMS therapy is likely to be of greater efficacy than any other available treatment for this patients refractory and severe depression.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for revision sacroiliac (SI) joint fusion surgery. Based on the submitted information and review of the North American Spine Society (NASS) guidelines, the revision SI joint fusion surgery is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. SI fusion may be appropriate for treatment of SI joint infection, tumor involving the sacrum, disabling pain due to sacroiliitis due to spondyloarthropathy, or SI pain due to severe traumatic injury or for multisegmental spinal constructs. However, SI joint fusion is not recommended for mechanical low back pain, non-specific low back pain, SI joint disruption in the absence of major pelvic fracture, degenerative sacroiliitis, SI joint osteoarthritis, or SI joint-mediated pain. In this patients case, there is a lack of indication that the patient received adequate relief from the initial surgery, as the patient reported a recurrence of symptoms when the patient initiated weight bearing within one month of the procedure. The provider noted the CT scan showed minimal bridging. However, this imaging study was only two months after the surgery, and a robust fusion mass would not be expected at that time. The recent MRI of the left hip seems to indicate progression of the left SI fusion. All told, the requested revision SI joint fusion surgery is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. One reviewer found that the requested revision SI joint fusion surgery is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: Two of the three reviewers determined that the requested services are 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:  One reviewer is board certified in orthopedic surgery and is actively practicing. One Reviewer is board certified in orthopedic surgery and is actively practicing.  One Reviewer is board certified in orthopedic surgery and is 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: Overturned

A 53-year-old male enrollee has requested clonazepam (Klonopin) 3 mg per day (1 mg, three times per day) for treatment of his chronic fatigue syndrome. Findings:  The physician reviewer found that in a head-to-head study with fluoxetine, Clonazepam showed fewer adverse events and better efficacy for anxiety disorder than the SSRI. The documentation provided shows poor work-up and monitoring. The patient has failed SNRIs and other therapies. Klonopin protocol at 3 mg per day is a reasonable request given this patients anxiety and fatigue. Further, cessation of Klonopin could place the patient at risk for severe exacerbation of his anxiety and panic disorder, which may lead to worsening chronic fatigue. Klonopin improves this patients fatigue and anxiety and is therefore supported as medically necessary.
Appeal type: Experimental/Investigational
Decision: Overturned

A 38-year-old female enrollee requested authorization and coverage of autologous bone marrow transplant for the treatment of catastrophic autophospholipid syndrome/severe systemic lupus.  The health plan denied the enrollees request indicating that the requested treatment is experimental.Three physician reviewers performed an experimental/investigational Independent Medical Review.  Each of the three physician reviewers concluded that autologous bone marrow transplant  is likely to be more beneficial for treatment of the enrollees catastrophic autophospholipid syndrome/ severe systemic lupus than any available standard therapy.  Because all three physician reviewers concluded that the requested treatment is likely to be more beneficial for treatment of the enrollees medical condition than any available standard therapy, the review organization overturned the health plans denial.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested the myRisk genetic testing for evaluation of the enrollees breast cancer status post bilateral mastectomy. Two physician reviewers found that screening for BRCA mutations is indicated in patients whose personal or family history predicts a high likelihood of finding one of these mutations. Identifying those who carry these mutations has clinical importance since it mandates the adoption of special measures aimed at risk reduction. Well-established guidelines identify those patients in whom genetic screening is warranted. This patient reports a history of invasive ductal breast cancer, and also reports two close relatives diagnosed with pancreatic cancer. As per National Comprehensive Cancer Network (NCCN) guidelines, she is as such eligible for  BRCA1 and BRCA2 testing. However, additional genetic tests included in the myRisk panel are not indicated. Therefore, the use of the myRisk genetic testing was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: Two 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:  One reviewer is board certified in clinical genetics and clinical biochemical genetics and is actively practicing. Two reviewers are board certified in internal medicine with sub-specialty certification in medical oncology 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: Upheld

A 53-year-old female enrollee requested authorization and coverage of botox injections for the treatment of tension, migraine headaches, and fibromyalgia.  The health plan denied the enrollees request indicating that the requested treatment is experimental.Three physician reviewers performed an experimental/investigational Independent Medical Review.  Each of the three physician reviewers concluded that botox injections are not likely to be more beneficial for the treatment of the enrollees tension, migraine headaches, and fibromyalgia than any available standard therapy.  Because all three physician reviewers concluded that the requested treatment is not likely to be more beneficial for treatment of the enrollees medical condition than any available standard therapy, the review organization upheld the health plans denial.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary:   An enrollee has requested ablation of the esophagus for treatment of his Barretts esophagus. The physician reviewer found that the superior effectiveness of the services at issue has not been established.  The published medical literature does not demonstrate that the requested procedure has been proven safe and effective in this clinical setting of Barretts esophagus with no dysplasia.  At this time, there is a lack of long-term data on the safety and benefit of radiofrequency ablation (RFA) for non-dysplastic Barretts esophagus.  Thus, RFA is not currently recommended for patients without evidence of dysplasia on biopsies.  In sum, ablation of the esophagus was not likely to have been superior over other treatment alternatives.  Final Result: The reviewer 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: The reviewer is board certified in internal medicine with sub-specialty 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.