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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for 16 hours per month of applied behavioral analysis (ABA) therapy (CPT H2019) and 16 hours per month of supervision (CPT H0032) for treatment of the enrollees medical condition. Findings:  The physician reviewer found that in review of the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested services. In this case, the patient presents with the diagnosis of autism spectrum disorder and co-occurring anxiety and depressive disorders. About one-third of individuals diagnosed with autism spectrum disorder are prescribed a serotonin-enhancing medication, which are first-line medicines for anxiety and depression. The records do not show utilization of pharmacotherapy. In addition, there is a lack of an objective assessment, via a standardized measure such as the Vineland or Adaptive Behavior Assessment System, to assess for maladaptive behaviors across multiple domains of functionality. The data from such testing is useful in developing quantifiable objectives as part of a larger multidisciplinary treatment plan.  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: Medical Necessity
Decision: Upheld

A 58-year-old female enrollee has requested coverage for Tracleer for treatment of her pulmonary hypertension. Findings:  The physician reviewer found that there is a lack of scientific evidence suggesting that Tracleer is superior for the treatment of patients in this clinical setting.  In the patients case, Letairis is medically appropriate.
Appeal type: Experimental/Investigational
Decision: Upheld

A 24-year-old female enrollee has requested for two WalkAide (external functional neuromuscular stimulator) devices (bilaterally) for treatment of her bilateral foot drop secondary to cerebral palsy.   Findings:  Three physician reviewers found that a review of literature reveals a paucity of quality literature on the use of WalkAides or functional electrical stimulation devices in patients with cerebral palsy, or in the general patient population. Studies are few, and are limited by small numbers and/or heterogeneous population and/or lack of control groups (see van der Linden and colleagues and Kerr and colleagues). The most recent quality study shows that while patients with cerebral palsy demonstrate improvement in walking due to decreased foot drop, there are no beneficial long-term treatment effects (see Merrill and colleagues).Because of a lack of supportive literature, especially for long-term benefit and effect, the use of bilateral WalkAides for this patient is not likely to be more beneficial than available standard therapies.
Appeal type: Experimental/Investigational
Decision: Upheld

A 63-year-old male enrollee has requested Sovaldi 400mg daily with Olysio 150mg daily concurrently for 24 weeks for treatment of his hepatitis C.  Findings:  Two physician reviewers found that in this patients case, the requested medication combination is not likely to be of greater benefit than other treatment options.  This patient meets the definition by the American Association for the Study of Liver Diseases/Infectious Diseases Society of America (AASLD/IDSA) for interferon-ineligibility.  Once-daily treatment with Olysio and Sovaldi, with or without ribavirin, has been shown to be effective in both treatment-naive patients and prior  responders infected with hepatitis C, genotype 1.  However, AASLD/IDSA guidelines caution that the efficacy and safety of Olysio have not been studied in patients with hepatitis C and moderate or severe hepatic impairment.   Thus, Olysio is not recommended in patients with moderate to severe hepatic impairment, as in this patients case.  All told, the superior efficacy of Sovaldi 400mg daily with Olysio 150mg daily concurrently for 24 weeks has not been established.
Appeal type: Urgent Care
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement of psychiatric treatment services provided from 10/28/15 through 11/24/15. Review of the submitted documentation indicates that during the period at issue there was no evidence of suicidality, homicidality, or grave disability. The patient showed no self-harming urges or behaviors. She was cognitively intact, and was not manic or psychotic. There was no evidence of impulsivity and no bizarre behavior. On admission, other than the reported `hot, sweaty, and dry mouth,` no withdrawal symptoms were reported.  There was no Clinical Opiate Withdrawal Scale (COWS) score documented upon admission. Vital signs were stable. Labs were within normal limits. The patient had no acute medical or psychiatric conditions necessitating the admission. At no time, either on admission or throughout her stay, was she in any life-threatening condition or situation.  The admitting physician made no indication that the patients situation was emergent in nature. Other than the admitting history and physical, no physician progress notes were provided. Suboxone tapers are commonly performed on an outpatient basis, and the nutritional supplements and microcurrent therapy prescribed did not require this type of structured setting. All told, the patient did not receive emergency medical services from 10/28/15 through 11/24/15. Final Result: The reviewer determined that the patient did not receive emergency medical services on the dates of service at issue. 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: Medical Necessity
Decision: Upheld

A 35-year-old female enrollee has requested residential treatment services for her chemical/chlorine toxicity.  Findings:  The physician reviewer found that there is no protocol for such testing found in the available scientific literature. Thus, there is no scientific evidence demonstrating the validity of the test that was performed to determine this patients chlorine toxicity. The additional problem with using chemical chlorine is the irritant or corrosive effect on the dermis. The skin testing is for assessment of IgE mediated reactions. While the sinusitis may indicate the need for aeroallergen testing, the patient did not appear to have any food related IgE mediated reactions. Even if there was an indication for food skin testing, the use of intradermal testing for foods (such as was done with avocado, wheat, etc.) is not recommended by the American College of Allergy, Asthma and Immunology (ACAAI) or the American Academy of Allergy, Asthma and Immunology (AAAAI), as listed in their practice parameters. These guidelines indicate that intracutaneous skin tests for foods are potentially dangerous, are overly sensitive, increase the chance of a false-positive test result, and are not recommended. (Bernstein, et al.) Additionally, immunotherapy using foods is not recommended by the ACAAI and AAAAI. The provider mentions in his letter that he makes his own vaccine from the purest substances available. It is unclear if these extracts are Food and Drug Administration (FDA) approved and they are not supported by the documentation provided. The metal assays that were performed were noted to have been developed and performance characteristics were determined by the diagnostic company who performed the test, which has not been cleared or approved by the FDA. Thus, this test would not be considered within the standard of care for determining toxicity in this patient.In review of the patients history and exams, the findings do not indicate an immune deficiency. Additionally, there is no laboratory results included that would corroborate the patients diagnosis. As this patients diagnosis was not confirmed by objective laboratory testing, the services at issue used to treat the patients chemical/chlorine toxicity are not considered medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

A 49-year-old female has requested coverage for past inpatient hospitalization services provided for treatment of her behavioral health issues.  Findings:  The physician reviewer found that inpatient psychiatric services provided to this patient during the dates at issue were not medically necessary. The clinical notes from a date at issue and forward show the patient to be cooperative, pleasant, social, and bright. The patients medications were changed prior to this date, and reflected a discontinuation of her listed admission medications. Active treatment could have been provided to the patient at a lower level of care as there was no evidence that she was unsafe or could not address all of her needs of daily living. The patient had the benefit of observation and treatment for two days prior to the dates at issue and showed no evidence of acute depression, psychosis, or active suicidal or homicidal ideation or intent after that date. As noted by the American Psychiatric Association (APA), the psychiatrist should determine the least restrictive setting for treatment that would most likely address patients safety and promote improvement in patients condition. The optimal treatment setting and patients likelihood of benefit from a different level of care should be reevaluated on an ongoing basis throughout the course of treatment. This patients records demonstrated that she was adherent with medications prescribed and actively participated in milieu therapies. All told, the patient could have been treated at the partial hospitalization program (PHP) or outpatient level of care, where she would have obtained equal benefit and had an opportunity to continue with treatment prior to returning home.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for the treatment plan, including surgery recommended by MD for treatment of the enrollees recurrent hernia status post repair. Findings:  The physician reviewer found that the records indicate the patient presented with a variety of pain complaints which may or may not have been related to the inguinal hernia. An open mesh repair was performed with some relief of the pain with recurrence nine months later. Two providers found that therapy should include nerve blocks to identify potential causative nerves with possible neurectomy but did not recommend removal and replacement of the mesh as no recurrence was noted. MRI imaging with valsalva did not demonstrate a recurrence according to an interpretation by a radiologist. A hernia specialist found that the MRI did show recurrence and recommended mesh removal with repeat mesh repair. As noted in the medical literature, mesh repair of inguinal hernias can be complicated by a variety of regional pain issues. The causes may include entrapped or injury to various nerves including the ilioinguinal and ileogenitalfemoral, as well as hernia recurrence. For the former causes, regional nerve blocks may be used, or if a specific causative nerve is identified, neurectomy may be beneficial. However, the MRI interpreted by the radiologist does not demonstrate recurrence and therefore a repeat surgical procedure may actually worsen the patients outcome. Based on these observations, the requested treatment plan, including surgery recommended by MD is not supported as medically necessary for treatment of this patients medical condition. 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 surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A patient has requested authorization and coverage for Bacillus Calmette-Guerin (BCG) plus interferon (IFN) combination therapy. Based on a recent literature review from colleagues, there is a paucity of evidence demonstrating improved patient health outcomes with BCG plus interferon (IFN) compared with BCG treatment alone in patients with non-muscle invasive bladder cancer. Additionally, a recent review of the role of IFN-alpha in non-muscle invasive bladder cancer continues to describe that the use of IFN-alpha combination to be without clear benefit for recurrent disease. Furthermore, a recent consensus statement, reviewed and restated the lack of efficacy with the addition of IFN-alpha to BCG for recurrent non-muscle invasive bladder cancer. Based on current National Comprehensive Cancer Network (NCCN) guidelines for recurrent non-muscle invasive disease, patients are recommended to be retreated with BCG or intravesical chemotherapy with gemcitabine or Mitomycin. Given these findings, the requested medication regimen consisting of BCG plus IFN combination therapy is not likely to be more beneficial than standard available therapies for treatment of this patients bladder cancer. Findings:  Three physician reviewers found the medication regimen consisting of BCG plus IFN combination therapy is not likely to be more beneficial than standard available therapies for treatment of this patients bladder cancer.Final Result: The reviewers determined that the medication regimen consisting of BCG plus IFN combination therapy is not likely to be more beneficial than standard available therapies for treatment of this patients bladder cancer.Credentials/Qualifications: Physician reviewer 1 is board certified in oncology and is actively practicing. Physician reviewers 2 and 3 are board certified in urology 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 57-year-old female has requested a CT needle guided core lymph node biopsy with Versed and propofol, bone/marrow biopsy/aspiration (with these two biopsies under one anesthesia session), blood count, metabolic panel and pathology services for treatment of non-Hodgkins lymphoma.  Findings:  The physician reviewer found that Non-Hodgkins lymphoma is separated into categories of low-grade lymphomas, intermediate-grade lymphomas, and high-grade lymphomas.  This patient originally presented with a low-grade lymphoma that subsequently transformed to a high-grade lymphoma.  Per the submitted records, it appears the stem cell transplant may have eradicated the high-grade component, leaving her with the low-grade component.  She now appears to have progressive lymphoma, and this is likely due to the low-grade component.  However, it is important to confirm this and fully stage the disease in order to plan future treatment or management.  In order to do so, the provider must re-biopsy the enlarging node, check various chemistries, and ascertain whether the bone marrow is involved.  Thus, the requested services are critical for this patients ongoing care.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a five-year-old female enrollee has requested speech therapy for the treatment of the enrollees autism. Findings:  The physician reviewer found that children with autism have deficits in speech and language, as well as social communication. Therapists with experience working with children on the spectrum, handling the myriad of communication challenges that face these children, are most appropriate. Research supports the utility of teaching social skills to children on the spectrum as well, with the expectation that skills learned in therapy can be generalized to different settings and people. Deficits in communication are integral to the diagnosis of autism, and are the foundation for many of the clinical findings. The sooner and more aggressively these deficits are targeted the better chance the child has for developing adequate skills to function in the community. Continued speech and language therapy is therefore medically necessary and appropriate for this patient.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Orthovisc vials purchased for injection and the series of injections that were subsequently administered. The submitted documentation supports the medical necessity of the requested services. The current literature continues to support the use of viscosupplementation for osteoarthritis of the knees. As noted by researchers, there is good evidence that intraarticular hyaluronic acid injections reduce pain and increase function in knee osteoarthritis, and the benefits are long lasting as compared with intraarticular corticosteroids. Evidence from real-life studies of repeat courses of intraarticular hyaluronic acid demonstrates an improvement in pain or function, a reduction in use of concomitant analgesia, and suggests that there may be a delay in the need for total knee replacement. Researchers performed a systematic review of overlapping meta-analyses comparing viscosupplementation with other nonoperative treatment modalities for knee osteoarthritis. Their review found that that the current highest level of evidence suggests that intraarticular hyaluronic acid is a viable option for knee osteoarthritis and that its use results in improvements in knee pain and function that can persist for long periods. Viscosupplementation has a good safety profile, and its use should be considered in patients with knee osteoarthritis. There is sufficient support for the services at issue in this clinical setting. Therefore, the Orthovisc vials purchased for injection and the numerous injections that were subsequently administered were medically necessary for the treatment of this patient.Final Result: The reviewer determined that the services at issue were and 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 orthopedic surgery 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 fifty year-old male who had coronary stents placed to the mid circumflex, RCA and RPDA coronary arteries is requesting authorization for a 64-slice CT angiography.Reviewers Findings:  The reviewing physician found that the CT angiography in an asymptomatic patient for evaluation for in-stent restenosis and coronary anatomy after PCI is considered an inappropriate indication for CT angiography per the American College of Cardiology guidelines.  The reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

A 52-year-old male enrollee requested authorization and coverage of a c-pap machine for the treatment of sleep apnea.  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 upheld the health plans denial on the basis that the requested equipment is not medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary:   An enrollee has requested food allergy testing for evaluation of his medical condition.  Two physician reviewers found that the use of food-specific IgG level does not predict true food hypersensitivity, and may actually be a marker of earlier development of food tolerance.  Food-specific IgG tests typically yield multiple positive results and may represent a normal immune response to foods.  The standard evaluation of food allergy consists of blood IgE level for foods and skin testing.  IgE immunoassays are in vitro assays used to identify food-specific IgE in the serum.  These tests are widely available, and immunoassays have demonstrated very high positive predictive accuracy for several of the major food allergens.  Values have been established for egg, milk, peanut, tree nuts, and fish that correspond to a positive predictive accuracy of 95%.  Skin testing for food-specific IgE is used in the diagnosis of IgE-mediated food allergies.   A positive skin test to a particular food indicates the possibility that the patient has true allergy to that food.  In conclusion, food allergy testing (IgG food laboratory testing) was not likely to have been superior over other methods of evaluation. 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 dermatology and is actively practicing. Two reviewers are board certified in internal medicine and allergy and immunology 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: Overturned

An enrollee has requested reimbursement for mental health residential treatment center services. The submitted documentation supports that mental health residential treatment center services were medically necessary. Applying the American Society of Addiction Medicine (ASAM) dimension analysis for placement with substance use disorders, the patient has met the criteria for Clinically Managed High-Intensity Residential Services. The patient required Clinically Managed High-Intensity Residential Services to maximize his chance of survival, which was contingent upon sobriety. In addition, given the patients age and the known physiological changes that come with age, he was at increased risk of falls and exacerbation of his diabetes mellitus if he continued to drink. Given the severity of the patients illness, residential treatment center services were clinically appropriate for the patient's illness. Therefore, mental health residential treatment center services were medically necessary for the treatment of the patients medical condition.Final Result: The reviewer determined that the services at issue were medically necessary for the 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.