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

The patient has requested authorization and coverage for Intravenous immunoglobulin (IVIG) treatment Gamunex-C. Gamunex-C is U.S. Food and Drug Administration (FDA) approved for the treatment of immune-mediated peripheral nerve disorders including Guillain-Barre syndrome, chronic inflammatory demyelinating polyneuropathy, and multifocal motor neuropathy. IVIG has been used increasingly with significant efficacy in the treatment of patients with disabling autoimmune forms of dysautonomia, which are most often small fiber polyneuropathies. Small fiber neuropathy is the most common cause of neuropathic pain in the peripheral neuropathies. Several open-label studies have suggested an immunological basis in small fiber neuropathy and have reported efficacy of treatment with IVIG (Wakasugi, et al; Weinstock, et al.). As such, immunological mechanisms may play a role in small fiber neuropathy. This patient has tried other types of medical therapies without improvement. Therefore, IVIG treatment Gamunex-C is medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested medication regimen 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 neurology 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: Urgent Care
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested services provided on an emergent or urgently needed basis.  Review of the submitted documentation demonstrates that a prudent layperson would not have sought immediate medical attention on the date in question. Upon review of the submitted medical records, the patient presented with a history of paroxysmal supraventricular tachycardia that resulted in symptoms prompting presentation to an emergency department at some unspecified time. However, based on the documentation submitted for review there is no evidence of syncope, significant hypotension, coronary ischemia or other acute change during supraventricular tachycardia. Paroxysmal supraventricular tachycardia can often be effectively managed with medication, and an ablation for paroxysmal supraventricular tachycardia is generally considered an elective procedure in the absence of the above urgent associated conditions. Further, the disputed services were not obtained on an immediate basis and were scheduled following the patients pre-ablation procedure. Based on the patients presenting complaints and symptoms as well as the length of time that transpired before treatment, a prudent layperson in this circumstance would not reasonably believe he was suffering from a serious medical condition that required immediate medical attention. In sum, the patient was not suffering from a serious medical condition that was likely to place the patients health in serious jeopardy, cause serious impairment to body functions or cause serious dysfunction to a body organ or part. Thus, the services in question did not meet prudent layperson criteria for emergency care or urgently needed services. As such, the Health Plans denial should be upheld.  Final Result: The reviewer determined that the patients symptoms did not meet prudent layperson criteria for emergency care or urgently needed services. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in cardiology 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 parent of an enrollee has requested reimbursement for residential treatment level of care services. Findings:  The physician reviewer found that the documentation provided do not support the medically necessity of the services at issue in this clinical setting. The progress notes indicate that the patient showed openness to discussion of her issues. She was cooperative in treatment.  During the period in dispute the patient did not show any dangerous behaviors towards herself or others. She was not displaying any significant or severe behavioral problems. It is evident that she needs more treatment to further improve her social functioning, depression, school participation, and family relationships. However, the records indicate that she did not need the restrictiveness of a residential psychiatric treatment facility. The medical literature support residential treatment when used for acute stabilization but is not evidenced based for long-term type treatment. Outpatient treatment and least restrictive options are considered first lines of care as referenced by the American Academy of Child and Adolescent Psychiatry. The standard of care for treatment of children and adolescents should be in the least restrictive setting as possible in order to maintain and foster natural supports. It is further recommended that children should be treated in the setting that is least restrictive and disruptive to their lives. Inpatient or residential treatment is indicated only in emergencies or for children who have not responded to efforts at outpatient treatment. There are benefits to in-home therapy due to the involvement with family as well as generalization of learned skills in a natural setting.  A study found that treatment outside of a residential setting is effective and are as beneficial as RTC programs: children in intensive in-home therapy were more likely in the future to live with family, make progress in school, not have trouble with the law, and have better placement permanence than youth in residential treatment. This patient could have been treated in a less restrictive setting safely and effectively. Therefore, RTC services during the dates of services in question were not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the services at issue were not medically necessary for treatment of the of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in in psychiatry with sub-specialty certification in child and adolescent psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 46-year-old male enrollee has requested for Lexapro for treatment of his condition. Findings:  The physician reviewer found that this patient has a long history of success with Lexapro. His depression returned. It would now be unsafe and inappropriate to deny the patient treatment with the drug that was shown to work.
Appeal type: Experimental/Investigational
Decision: Upheld

A 47-year-old male enrollee has requested for multilevel artificial disc replacement surgery utilizing Prodisc for treatment of his back pain. Findings:  Three physician reviewers found that The discogram that was reportedly positive at all levels is an invalid and scientifically unsound study.  It cannot support a request for multilevel disc surgery.  Furthermore, there is insufficient scientific evidence supporting the long-term safety and efficacy of artificial disc replacement especially at multiple levels. The patient has other treatments available that are likely to be more beneficial.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the residential treatment level of care services for treatment of the enrollees behavioral health issues. Findings:  The physician reviewer found that The progress notes indicate that the patient had continued withdrawal symptoms during the admission. He had constant verbal outbursts toward staff and peers and was minimally invested in his treatment. He had previously failed PHP and IOP levels of care recently and had no significant period of sobriety outside of a controlled environment. Applying the American Society of Addiction Medicine (ASAM) criteria to determine level of placement, this patient had continued withdrawal symptoms (score 3), no co-morbid serious medical problems (score 0), emotional, behavioral or cognitive conditions and complications were serious given the patients mood and paranoia issues that were unstable (score 3), and the patient demonstrated a lack of motivation to change and minimal if no investment in treatment (score 3). The patients continued use or continued use potential was severe as the patient did not demonstrate any history of sobriety outside of a controlled setting within the past several years (score 3), and his recovery and living environment was noted to be stressful (score 2). Overall the patients presentation suggests risk rating scores in the range of above 3 in several categories. This overall risk rating recommends the patient be treated with residential services, 24-hour care with more intense milieu anger treatment. Due to the fact that the patient was preoccupied with substance use, had no job or social skills to maintain sobriety, had little insight and a longstanding history of substance abuse, he met the criteria for RTC level of care admission and treatment. Thus, the RTC services were medically necessary for treatment of this patients medical condition. 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 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 53-year-old female enrollee has requested for the medication Procrit for treatment of her normochromic normocytic anemia. Findings:  The physician reviewer found that Erythropoietin (Procrit) should be started in this case with the presumptive diagnosis of a chronic inflammatory state. The target hemoglobin should be pre-determined and carefully monitored. Further workup and second opinion on the bone marrow exam would be appropriate to rule out myelodysplasia (MDS), a diagnosis in which ESA use would be indicated as well.
Appeal type: Experimental/Investigational
Decision: Upheld

A female enrollee requested the ColonSentry laboratory test for medical evaluation of her medical condition.  Findings:  Three physician reviewers found that the ColonSentry test is a blood-based panel made up of biomarkers that have been determined to be predictive of a patient having colon cancer. In clinical practice in the United States, it is used rarely compared to other non-invasive tests such as stool fecal occult blood test, fecal immunochemical testing, and stool DNA testing.  All told, the ColonSentry laboratory test was not likely to be of greater benefit than other available modalities.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for 20 hours per week of applied behavioral analysis (ABA) therapy.Findings:  The physician reviewer found that Based on the Council of Autism Service Provider (CASP) guidelines for autism and the ABA Coding Coalition, the essential components of documentation to support ABA services includes the submission of a treatment plan developed from a thorough assessment of the patients skills. This patients caregiver has requested authorization of 20 hours of ABA per week. However, the records do not include documentation of a treatment plan to support the requested ABA services. In addition, the most recent providers notes dated 6/18/20 recommended 15 hours of ABA services per week. Moreover, the patient does not meet the medical necessity criteria outlined by Papatola and Lustig, which states that medically necessary ABA services 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 these criteria, the requested 20 hours of ABA services per week fail to meet criteria (a), (c), and (d). Without an authorization request based on a thorough assessment of skill, the requested services have not been shown to meet the essential health needs of the patient. In the absence of this information, the requested services have not been established to be for purposes other than the convenience of the provider or patient, and it is unknown whether they are consistent with the patients diagnosis. Given these findings, the requested 20 hours per week of ABA therapy is not medically necessary to decrease disability and correct or ameliorate the patients behavioral conditions.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 a licensed B.C.B.A, board certified in psychology, 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: Overturned

A 44-year-old male enrollee has requested a laparoscopic sleeve gastrectomy for treatment of his obesity. Findings:  Three physician reviewers found that the laparoscopic sleeve gastrectomy is a well-established procedure for the treatment of morbid obesity. The safety and efficacy of the sleeve gastrectomy has been sufficiently studied. The procedure is an approved primary procedure by the American College of Surgeons and the American Society of Metabolic and Bariatric Surgery. Weight loss outcomes of five years show weight loss that is comparable to other restrictive procedures with an acceptable complication profile. Health outcomes related to improvement of weight-related co-morbid conditions have been shown to also be comparable to other restrictive procedures. In the case of this patient, he has several co-morbid conditions that are contraindications to LRYGBP. All told, laparoscopic sleeve gastrectomy is the most appropriate procedure in this particular setting.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Makena in weekly dosage starting at 24 weeks to 36 weeks of pregnancy for treatment of the enrollees high risk pregnancy. Findings: The physician reviewer found that as noted by the American College of Obstetricians and Gynecologists (ACOG), in its practice bulletin, a woman with a singleton gestation and a prior spontaneous preterm singleton birth should be offered progesterone supplementation starting at 16-24 weeks of gestation, regardless of transvaginal ultrasound cervical length, to reduce the risk of recurrent spontaneous preterm birth. However, the ACOG further noted that progesterone treatment does not reduce the incidence of preterm birth in women with twin or triplet gestations and, therefore, is not recommended as an intervention to prevent preterm birth in women with multiple gestations. Thus, the ACOG supports progesterone treatment for the prevention of preterm birth in patients with a history of preterm delivery, in singleton gestations only. The records indicate that this patient has a twin gestation. Therefore, the requested Makena in weekly dosage starting at 24 weeks to 36 weeks of pregnancy does not meet the standard of care. 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 obstetrics and gynecology 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 two-year-old twin who was born premature and has chronic lung disease. The patients parent is requesting authorization for Synagis injections for the winter months. This request has been denied by the Health Plan.Analysis and Findings:The patient does not meet the nationally accepted guidelines for consideration of Synagis. Specifically, the American Academy of Pediatrics recommends Synagis before the start of the RSV season for children with chronic lung disease who have required medical therapy for chronic lung disease within six months before the anticipated start of RSV season, and who are less than two-years-old. Although this patient has chronic lung disease, she is not less than two years of age. In addition, she does not meet other qualifying criteria for consideration of Synagis. Therefore, Synagis is not recommended for this patient. Accordingly, I have determined the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

A 58-year-old female enrollee requested authorization and coverage of Heidelberg retinal tomography (HRT). The Health Plan denied the request indicating that the requested procedure is not medically necessary for evaluation of the enrollees vision.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plans denial on the basis that the requested procedure is medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

A 29-year-old female enrollee has requested for a dermatology consultation to treat acne for treatment of her acne. Findings:  The physician reviewer found that the patient has moderate acne and has been treated with Retin-A cream without improvement.  The Health Plan guidelines require a failure of conservative treatment, including an eight-week trial of topical antibiotics or a two-month trial of oral antibiotics.  Additionally, if therapy with isotretinoin is indicated, intralesional injections of acne cysts are indicated, or if there is the development of scarring, then dermatology referral is covered.  These criteria are medically reasonable and appropriate, and this patient has not yet met these criteria for referral.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the radiofrequency neurolysis of the left L3, L4 and L5 medial branch nerves (L4-5, L5-S1 facet joints). The majority of the studies focusing on lumbar facet joint treatments suggest that radiofrequency ablation significantly reduces pain in well selected patients. The records indicate that this patient underwent this procedure in the past with a good result with pain relief lasting several years. Based upon the current literature and the patients results associated with the prior radiofrequency ablation procedures, the request for a repeat procedure was appropriate.  Furthermore, it is likely to be of more benefit for the patients lumbar facetogenic pain than any other standard procedure. Thus, the radiofrequency neurolysis of the left L3, L4 and L5 medial branch nerves (L4-5, L5-S1 facet joints) were likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.One reviewer found that the radiofrequency neurolysis of the left L3, L4 and L5 medial branch nerves (L4-5, L5-S1 facet joints) were not 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 services at issue were 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:  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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for partial hospitalization program (PHP) services and intensive outpatient program (IOP) services for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found that the patient showed no post-acute withdrawal symptoms. He was medically stable. the patient was cognitively intact and able to provide for his activities of daily living. With the exception of isolated occurrences the patient was compliant with the patient's medication and treatment regimens. The patient had episodic outbursts of anger in which the patient punched walls, slammed doors and used profanity. These episodes were not directed at others, only at inanimate objects, therefore the patient is not considered to be a danger to others. The patient denied suicidal or homicidal ideation. The patient was stable on a medication regimen and Trileptal was added later in the admission, which was tolerated well. The patient had plateaued with respect to any significant change in behavior. Although the patient had obtained and sponsor and employment, no major behavioral changes occurred in treatment course after that period of time. The gains made, such as higher compliance with treatment planning, could have been achieved on an outpatient basis. Since his family situation was not optimal, a community based support system could have been developed along with 12-step meetings. Final Result: The reviewer determined that a portion of the services at issue were 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 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.