Persius/imr-appeals huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Upheld

A 45-year-old male enrollee has requested implantation of a trial, and subsequently a permanent, spinal cord stimulator for the treatment of his back pain. Findings:  Three physician reviewers found that the medical records submitted in this case do not support a specific and definitive diagnosis for this patients clinical symptoms. Diagnosis of a musculoskeletal condition requires a detailed neurological and musculoskeletal examination. This is particularly true in the case of diffuse spinal pain, such as in this case where the patient reports cervical and lumbar pain. A complete physical examination of the patients neurological and musculoskeletal system is not documented in the records provided; general mention of tenderness to palpation range of motion of the spine is the primary finding noted. Additionally, the submitted medical records do not document prior diagnostic studies upon which the spinal diagnosis was made. Furthermore, limited documentation of the patients neurological function has been provided. Moreover, mental health clearance is generally required prior to trial of a spinal cord stimulator (with subsequent permanent placement).
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 48-year-old female who is perimenopausal and was referred for a DEXA scan because of a positive family history of osteoporosis. This scan of the left and right hips revealed T scores of -2.3 and -2.5. The etiology of the low bone density is unknown and a presumptive diagnosis of osteoporosis was suggested by the patients provider. Based on a history of multiple sclerosis, petit mal seizures and a family history of osteoporosis, the patient was considered to be at high risk for falls. She was fitted with a hip protector and instructed to return in a year for another DEXA scan. There is no history of fragility fractures and no additional risk factors beyond her T scores and the possibility that she might fall. The patients provider indicated that her bone resorption markers (urinary NTx, and serum NTx and CTx) were below target for bisphosphonates and that her bone formation markers were low.  It appears that based on a recent extension of a combination therapy study in postmenopausal women, the patients provider has recommended a two-year course of the anabolic agent Forteo, followed by a bisphosphonate. The Health Plan denied the providers request for authorization of Forteo based upon a determination that the therapy is not medically necessary.Although the patient most likely has osteoporosis based on the dual total hip DEXA scan and her family history, she has no history of previous falls or fractures or any other risk factors. Her provider wishes to place her on Forteo due to low bone turnover imputed from low bone resorption and bone formation markers. In theory, a patient with low bone turnover would not be expected to improve bone formation by slowing bone resorption with a bisphosphonate since resorption is low to begin with and resorption and formation are coupled.  The provider indicated intent to reevaluate bone markers following three and six months of Forteo therapy to determine efficacy.  Treatment might potentially be continued for up to two years if there is significant change in bone markers. Any improvement in bone mineral density would then be consolidated with a bisphosphonate. Presently there are no definitive guidelines for the use of bone markers by reason of the tremendous variability in the values within a single agent. Values may vary with age, season and the time the specimen is taken.  The current recommendation is to reserve Forteo for those women who have failed other treatments. Failure is defined as statistically/clinically significant decreases in bone mineral density, the occurrence or recurrence of fragility fractures while on treatment, intolerance to these treatments, very severe osteoporosis (T-scores greater than -4.0) or high risk for fractures such as old age, family history of hip fractures, smoking or as assessed by various fracture risk indices.  The patient is not within the subset of women for whom Forteo therapy is indicated.  Therefore, I have determined the requested therapy is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for Applied behavior analysis (ABA) therapy services: direct 1:1 ABA services, supervision by BCBA, caregiver training, and a re-assessment. Medical guidelines for the treatment of patients with autism spectrum disorder detail essential assessment and treatment components to support a treatment plan. In this patients case, the provider did not include direct observable forms of data collection in their analysis, and the provider did not report standardized measures throughout the patients treatment. In addition, the ABA services fail to meet several requirements outlined by researchers. According to researchers, documentation to support medical necessity criteria includes a) Diagnostic and Statistical Manual of Mental Disorders 5 (DSM-5) autism diagnosis supported by symptoms; b) symptoms of diagnosis causing impairment; c) motivation for change exemplified by family involvement; d) interventions are evidence-based and consistent for type, frequency, and duration of treatment; e) goals are constructed with patients family; f) outcomes are measurable; g) occurs in least restrictive environment; h) required for purposes other than convenience of patient or provider; i) measurable reduction in symptoms; j) symptoms are manageable; and k) day-to-day functioning has improved over baseline. The submitted information fails to meet criteria (a) and (b). Specifically, the submitted psychological assessment from 2005 was based on DSM-IV criteria, and none of the assessments used were specific to autism. On review of the available records, there is a lack of an updated information to fully elucidate the depth of the patients delays and autism specific symptoms to support the ABA services as requested. Moreover, the ABA services are not in accordance with the generally accepted standards of mental health and substance use disorder care or clinically appropriate in terms of type, frequency, extent, site, and duration for treatment of this patient. Given these findings, the ABA therapy services: direct 1:1 ABA services, supervision by BCBA, caregiver training, and re-assessment were not and are not medically necessary for treatment of this patient.Final Result: The reviewer determined that the services at issue were not and 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: Medical Necessity
Decision: Overturned

The patient is a 31-year-old female status post massive weight loss after gastric bypass surgery for morbid obesity. The patient underwent a panniculectomy for a large panniculus and is seeking further procedures to remove the massive amounts of redundant skin. The procedures she is seeking are: brachioplasty, thigh lift, and breast lift. No evidence of any breast evaluation has been submitted; thus, it is unclear whether the appropriate procedure in this case would be a breast lift or a breast reduction. The Health Plan has denied authorization for a referral to a plastic surgeon indicating that the requested procedures are not medically necessary for treatment of the patients condition.No evidence has been provided which demonstrates that brachioplasty and thigh lift procedures are medically necessary for treatment of this patients excess skin. As such, these procedures are considered cosmetic in nature and are not medically indicated. However, the patient indicates that she experiences back pain due to the size of her breasts. The submitted information does not note the condition of the patients breasts or back. Therefore, the patients request for a breast procedure may be medically indicated depending upon the results of an evaluation by a plastic surgeon. Based upon the information set forth above, I have determined that the requested referral to a plastic surgeon for evaluation of the patient for a breast procedure is medically necessary. However, the requested brachioplasty and thigh lift procedures are not medically necessary. Therefore, the Health Plans denial should be partially overturned.
Appeal type: Experimental/Investigational
Decision: Upheld

A male enrollee requested artificial disc replacement C6 and C7 for medical treatment of his medical condition.  Findings:  Three physician reviewers found that there is lack of information regarding significant neurological deficits to include decreased motor strength, decreased deep tendon reflexes, and a positive Spurlings test.  Additional studies are needed to support the long-term efficacy of the services at issue.  In sum, artificial disc replacement C6 and C7 was not likely to have been of greater benefit than other treatment options.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Guardant360 testing provided on 2/15/17 for evaluation of the enrollees non-small cell carcinoma. The patient presents with biopsy proven metastatic non-small cell lung cancer. In this clinical setting molecular diagnostic studies are considered the standard of care. Numerous gene alterations have been identified that impact therapy selection. The National Comprehensive Cancer Network (NCCN) guidelines for  non-small cell lung cancer strongly advises broader molecular profiling with the goal of identifying rare driver mutations for which effective drugs may already be available, or to appropriately counsel patients regarding the availability of clinical trials. Broad molecular profiling is a key component of the improvement of care of patients with non-small cell lung cancer. Testing of lung cancer specimens for these alterations is important for identification of potentially efficacious targeted therapies, as well as avoidance of therapies unlikely to provide clinical benefit. Therefore, the Guardant360 gene testing provided was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: Two of three reviewers determined that the testing 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: Physician reviewer number one is board certified in internal medicine with sub-specialty certification in medical oncology 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.Physician reviewer number two is board certified in internal medicine with sub-specialty certification in medical oncology 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.Physician reviewer number three is board certified in internal medicine with sub-specialty certification in medical oncology 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

Nature of Statutory Criteria/Case Summary: At issue is whether the occipital nerve block therapy that was provided was likely to have been more beneficial for the treatment of the patients condition than any available standard therapy. The enrollee was diagnosed with chronic migraine headache, occipital neuralgia, lesser occipital nerve, and TMJ disorder. Bilateral occipital nerve blocks were performedTwo out of three physician reviewers found that occipital nerve block therapy is a common outpatient procedure performed by pain specialists and headache specialists for a variety of indications, including migraine and occipital neuralgia. This patient has migraines, possibly chronic migraines, and has been diagnosed with occipital neuralgia.  The medical literature supports the services at issue in this clinical setting. Consensus guidelines are also supportive of the use of this procedure. Therefore, the provided occipital nerve block therapy was likely to have been more beneficial for the treatment of the patients condition than any available standard therapy. One out of three physician reviewer found that the evidence on the use of GONBs remains weak.Final Result: The reviewers determined that the requested occipital nerve blocks were likely to have been more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in neurology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 36-year-old male enrollee requested authorization and coverage of intensive outpatient therapy for the treatment of schizo-affective disorder with recurring paranoia and hallucinations .  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 services are not medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

A female enrollee requested the Acellular Derm Matrix Implant (CPT code 15777) and the Flexhd/Allopatchhd/Matrixhd (code HCPCS-Q4128) for medical treatment of her right breast capsule contracture.   Findings:  Two physician reviewers found that the placement of an acellular dermal matrix or other matrix material during a capsulectomy for a breast periprosthetic capsular contracture is widespread, with many surgeons considering this to be the standard of care for a breast augmentation revision for the reason of a pathologic capsular contracture. Given these findings, the use of the Acellular Derm Matrix Implant (CPT code 15777) and the Flexhd/Allopatchhd/Matrixhd (code HCPCS-Q4128) was likely to have been more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested Ritalin 300 mg a day (10 mg, 6 pills 5 times a day) for treatment of the enrollees behavioral health condition.  Findings: The physician reviewer found that there is a lack of evidence based, peer reviewed literature to support the requested Ritalin 300 mg a day (10 mg, 6 pills 5 times a day) for the treatment of this patient. There is no true pharmacological precedent to support the use of amphetamines, high dose or otherwise, as antidepressants with sustained response over time. More evidently, doses of this nature have been associated with cardiovascular and cerebrovascular risk as well as tachyphylaxis. Moreover, the submitted documentation does not show that this patient has tried and failed all other conventional methods of treatments. The options of bupropion and modafinil were discussed with the treating provider in July 2016, but the patient was against trying these new medications. Therefore, given the lack of support in the medical literature and based on standard guidelines, the requested Ritalin 300 mg a day (10 mg, 6 pills 5 times a day) is not medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: The physician 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

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for a referral to a dermatologist.According to the American Academy of Family Practice physicians, a PCP is essential in serving as a patients first contact for health concerns. Additionally, the authors indicate that the PCP aids in navigating the health care system with patients, including specialist and hospital care coordination and follow-up. Medical literature indicates that PCPs are well educated on common skin conditions, including atopic dermatitis, acne vulgaris, cellulitis/abscess, verruca vulgaris, and benign skin lesions. It would be medically reasonable and appropriate for the PCP to evaluate the patients skin concerns and refer to a dermatology specialist if clinically warranted. In this case, the patient has a skin complaint that should be evaluated. The family history of skin cancer, while important, would not affect the decision to have the PCP evaluate the patients concerns. The medical literature does not support a referral to a dermatologist at this time. It would be within the standard of care for a PCP to evaluate the skin concern initially. Therefore, the requested referral to a dermatologist is not medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the requested service 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 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: Medical Necessity
Decision: Upheld

The parent of a 14-year-old male enrollee has requested growth hormone therapy Humatrope (somatropin) for treatment of the enrollee, who has a reported decelerating growth velocity. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested therapy.  This patients height is not more than two standard deviations below normal.  His growth velocity is appropriate for a young male who is in early puberty.  The patients screening IGF-1 level is normal, and final adult height prediction, based on the bone age and height measurement, is 68.5 inches.  This is a normal adult height prediction and does not warrant growth hormone treatment.  The medical records are consistent with constitutional delay, not growth hormone deficiency.  All told, growth hormone therapy Humatrope (somatropin) is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Findings:  The physician reviewer found that the parent of an enrollee has requested authorization and coverage for Saizen (5 mg vial, daily). Based on the available documentation, this patients height is not more than two standard deviations (SDs) below the mean for age and gender, his bone age is not significantly delayed, and his growth velocity is normal. Moreover, the patients growth factors are normal, and there is no known morphological abnormality of the pituitary gland. While the patients adult height prediction is more than two SDs below the genetic target height, it is still within normal limits for U.S. adult males and not short enough to warrant a trial of growth hormone therapy for treatment of idiopathic short stature. Growth hormone treatment for idiopathic short stature was approved for males with adult predicted height of less than 63 inches, and this patient does not meet standard criteria for a trial of growth hormone therapy. All told, the requested Saizen (5 mg vial, daily) is not supported as medically necessary for treatment of this patients medical condition. 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 pediatrics with sub-specialty 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: Upheld

The patient is a 55-year-old woman with a history consistent with an anxiety disorder. Her recent family and legal issues have apparently exacerbated her anxiety. The patient has been treated with benzodiazepines including Xanax, Ativan, and Klonopin. The submitted records do not indicate that any other medications were tried. The patient apparently only had beneficial results with Klonopin wafers. No records of any psychiatric consultation have been provided. The Health Plan indicates that Klonopin wafers are not medically necessary for treatment of the patients condition.The patient has only undergone trials of treatment with benzodiazepines. No attempts of non- medicinal treatment of the patients anxiety have been documented. In addition, there have been no documented trials of other classes of medications including tricyclics, selective serotonin reuptake inhibitors, beta-blockers, or Buspar. Trials of other medical and psychotherapeutic treatments should be attempted for treatment of the patients anxiety. Based upon the information set forth above, I have determined that the requested medication is not medically necessary for the treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

A 51-year-old female has requested coverage for a parathyroid nuclear study for evaluation of her hyperparathyroidism. Findings:  The physician reviewer found that the appropriate therapeutic approach in this case appears to be a parathyroidectomy. If a single adenoma can be demonstrated preoperatively, surgery can be performed by a minimally invasive procedure. As such, it is medically appropriate to perform a parathyroid nuclear study in this setting. The proposed study is within the standard of care and should be authorized
Appeal type: Medical Necessity
Decision: Overturned

A 35-year-old female enrollee requested authorization and coverage for gastric bypass surgery. The Health Plan denied the request indicating that the requested procedure is not medically necessary for treatment of the enrollees morbid obesity.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.