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

A fifty-nine year-old male with benign seborrheic keratoses is requesting authorization of surgical excision.Reviewers Findings:  The reviewing physician found that in cases where a possible skin cancer is identified, surgical excision is medically appropriate and within the standard of care.  The reviewing physician found that the Health Plan denials should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

A sixty-two year-old male with a spinal dural arteriovenous fistula is requesting authorization for treatment services at an out-of-network.  Reviewers Findings:  The reviewing physician found that it is essential the patient receive the highest level of care available as soon as possible, therefore, the requested services are medically necessary.  The Health Plan denial was overturned.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:   An enrollee has requested Sovaldi and Daklinza for treatment of his hepatitis C virus. Findings:  The physician reviewer found that according to joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with life expectancy less than 12 months due to non-liver-related conditions. In non-cirrhotic genotype 3 patients who have failed peg-interferon and ribavirin, therapy is recommended with Sovaldi and Daklinza for 12 weeks (regardless of interferon eligibility). This is based on the ALLY-3 study, which showed a high cure rate. This patient is ineligible for alternative interferon or ribavirin-containing regimens due to a medical condition which can be exacerbated by interferon or ribavirin. The guidelines cite study data reporting that delay in treatment may result in decreased survival. For these reasons, the requested treatment with Sovaldi and Daklinza is medically necessary for the treatment of this patients hepatitis C infection. Final Result: The reviewer determined that the requested medications 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 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.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for sclerotherapy for treatment of the enrollees vascular ectasias. Findings:  The physician reviewer found that review of the submitted documentation and relevant literature fails to demonstrate the medical necessity of the service at issue. In this case, the patient has vascular ectasias, also known as telangiectasias and reticular veins, of the lower legs and feet. The documentation submitted for review does not demonstrate the patient has a diagnosis of bleeding or ruptured superficial varicose veins or skin ulceration or residual symptomatic superficial varicosities after vein stripping or ablation. In this clinical setting, the service at issue was cosmetic and not medically necessary. For the reasons provided, the sclerotherapy was not medically necessary for treatment of the patients medical condition.  Final Result: The reviewer determined that the service at issue was 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 patient is a 55-year-old male with a diagnosis of ADHD.  He has been treated with stimulants for this condition and reports a positive but limited clinical response.  He has started Focalin XR and finds that his best response is at 40mg, double the dosage approved by the FDA. The patient states that he notes an increase in his blood pressure with the combination of 20mg Focalin XR and additional dexedrine spansules. This is not unexpected since the combination of the Focalin XR with other types of dexedrine is not recommended due to side effects that include elevation in blood pressure.At issue is whether Focalin XR at a dosage of 40mg per day is medically necessary for treatment of the patients medical condition.Focalin XR is compounded so it will be safe and effective when used one time per day.  Additional stimulant medication is not recommended with Focalin XR. The FDA approved Focalin XR at a maximum dosage of 20mg per day. The request for twice the dosage based upon a subjective finding of the patient is not an appropriate clinical rationale to exceed the recommended dosage.  It is also of concern that the patient is reporting side effects with an increase in blood pressure.  Furthermore, Focalin XR can be addictive and has abuse potential.  In light of these safety concerns, the patient should not exceed 20mg of Focalin XR per day and should not use any additional type of dexedrine compound with the mediciation. For the reasons stated above, I have determined the requested dosage is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

The parents of a 15-year-old male enrollee have requested authorization and coverage for continued treatment in a residential treatment center for treatment of their sons severe major depression with psychotic features.  The health plan has denied this request indicating that continued residential treatment is not medically necessary for treatment of the enrollees medical condition.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.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested Harvoni for treatment of his hepatitis C virus. Findings: The physician reviewer found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. The guidelines recommend that treatment-naive genotype 1a patients should be treated with Harvoni for 12 weeks. These guideline recommendations are based on multiple randomized clinical trials, and the medication is U.S. Food and Drug Administration (FDA)-approved for all patients with chronic hepatitis C genotype 1 regardless of fibrosis stage. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, the requested treatment with Harvoni  is supported as medically necessary for the treatment of this patients hepatitis C infection.  Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: The physician 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.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: A 29-year-old male enrollee has requested authorization and coverage for a Mueller wide-mouth sports water bottle. As noted in the medical literature, the incidence of feeding difficulties in patients with intellectual disability is high. Successful management of feeding and swallowing difficulties decreases morbidity. However, the requested Mueller wide-mouthed sports water bottle is not medically necessary for treatment of the patients medical condition. The specific water bottle cannot be regarded as an item of durable medical equipment. All told, the requested Mueller wide-mouth sports water bottle is not medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the requested device 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 and neurology with special qualification in child 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: Medical Necessity
Decision: Upheld

The patient is a 16-year-old female who has a history of oppositional/defiant behaviors manifested by truancy from school, verbal altercations with her mother and aunt and running away from home for a period of three weeks. She started outpatient psychotherapy and was prescribed Zoloft but had reportedly refused to take the medication and stopped seeing the psychiatrist. The patient also had a history of smoking marijuana and drinking alcohol. There was a report of some self-mutilation, but no evidence of psychotic behavior or suicidal ideation prior to admission to the residential treatment facility that utilized a 12-step program. Her admission diagnoses included major depressive disorder with polysubstance abuse and oppositional/defiant disorder (ODD).  The patients mother has requested reimbursement for residential treatment services provided from August 2006 through September 2006. The Health Plan denied her request based upon a determination that admission to residential treatment was not medically necessary.A review of the clinical record for dates of service August 2006 through September 2006 reveals no manifestation of self-destructive behaviors such as self-mutilation or suicidal ideation nor did the patient manifest behaviors suggestive of a thought disorder. The patient was diagnosed with a major depressive disorder and there was a psychiatric consultation suggesting a possible bipolar disorder with borderline features. There was no documentation of weekly, face-to-face psychiatric sessions. The therapy sessions and discharge summary were conducted by a Masters prepared therapist. The primary modalities of treatment were generic and utilized the 12-step group model. The patient did receive individual therapy sessions which provided an opportunity for personal disclosure of sexual identity issues and anger and resistance about a proposed family move and having to leave friends behind. The patients mother missed many of the parenting classes but did come to several family therapy sessions.  The documentation provided indicates the patient did not meet standard criteria for admission to a residential treatment program with a primary focus on substance abuse rehabilitation. The primary issues with the patient were related to her sexual identity, her depression and her relationship with her mother. Additional concerns regarding the possible diagnosis of a bipolar disorder were raised, but not adequately addressed during her inpatient stay. The patient did not require 24-hour nursing supervision and an intensive outpatient program with a focus on the interaction of the patient and her mother would have been more appropriate.Based upon the information set forth above, I have determined the services at issue were 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: An enrollee has requested authorization and coverage for Xanax or Valium for treatment of the enrollees behavioral health conditions. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medications in this clinical setting.  Benzodiazepines possess an array of potential side effects.  Disinhibition, cognitive dulling, perceptual disturbances and exacerbation of depression are common, while a connection with Alzheimers disease later in life has been suggested in the peer-reviewed literature.  Additionally, there is growing concern of misuse, tolerance and dependence issues with this medication class.  Contemporary practice standards aim to minimize benzodiazepine therapy and optimize treatment alternatives.  Per the records, the risks of benzodiazepine therapy outweigh the potential benefits in this patients case.  The patient is prescribed an opioid analgesic.  Benzodiazepines should be avoided in patients treated with opioid therapy.  Further, the patient reportedly has a history of addiction.  Benzodiazepines should be avoided in patients with history of addictive illness.  In terms of medication alternatives, the patient has not failed an adequate trial of pro-serotonergic medicines, which represent first-line interventions for generalized anxiety and depression, some of which, the serotonin-norepinephrine reuptake inhibitors (SSRIs), can also help with pain.  The record illustrates that the patient has been presented reasonable somatic alternatives but declined those treatments.  Finally, it does not appear that the patient has pursued a structured course of dialectical behavior therapy or cognitive behavioral therapy for pain, anxiety and/or depression.  Thus, Xanax or Valium are not medically indicated for the treatment of this patient. Final Result: The reviewer determined that the requested medications 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Afirma Gene Expression Classifier testing performed.Findings:  The physician reviewer found that While a fine needle aspiration biopsy of a suspicious thyroid nodule is typically an accurate means of assessing whether the nodule is benign or malignant, approximately 15% of fine needle aspiration biopsy results are considered to be indeterminate. Until recently, the only way to establish whether the nodule was thyroid cancer was via surgical excision, even though the majority of the cases turn out to be benign.  Afirma Gene Expression Classifier testing utilizes a gene expression classifier in order to help determine the likelihood of malignancy of nodules with indeterminate cytology on fine needle aspiration biopsy, thereby decreasing the need for unnecessary surgeries.  Because it is very sensitive and has a high negative predictive value, a negative Afirma result is rather suggestive of a benign nodule and can therefore preclude such surgical procedures.  Therefore, Afirma Gene Expression Classifier testing performed on the disputed date in question was likely to have been superior over other methods of evaluating this patient.Final Result: The reviewers all three determined that the services at issue were 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 reviewers 1, 2& 3 are board certified in internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism 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 59-year-old female enrollee has requested Acthar for treatment of her systemic lupus erythematosus (SLE).   Findings:  The physician reviewer found that review of the submitted documentation demonstrates the medical necessity of the requested medication. Bomback and colleagues assessed the use of Acthar gel in the treatment of nephrotic syndrome performing a trial of 21 patients, which reported partial or complete remission in 11 patients (Bomback et al, Drug Des Devel Ther). The authors also found that proteinuria was reduced to less than 500 mg/24 hours in four patients in this study (Bomback et al, Drug Des Devel Ther). In a prospective, open-label study, Acthar gel was used in 15 patients with resistant glomerular disease and showed promising results, with two of five resistant membranous nephropathy patients achieving clinical remission (Bomback et al, Am J Nephrol). Reported adverse effects were similar to adverse effects of corticosteroids (weight gain and hyperglycemia.). In addition, the alternative therapies, including high-dose corticosteroids, cyclophosphamide, and rituximab, all have significant potential toxicities. Therefore based on the reasons provided above, Acthar gel is both reasonable and medically necessary for control of the patients proteinuria.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a consultation with a surgical provider appropriately qualified to perform laser spine surgery. The medical literature reveals that for the small minority of low back pain patients with severe or progressive motor weakness, or signs and symptoms of cauda equina syndrome, urgent evaluation by a neurosurgeon or orthopedic surgeon with experience in back surgery is indicated. There is no evidence that early referral for surgery, in the absence of severe or progressive neurologic deficits, improves outcomes for lumbar disc prolapse with radiculopathy or symptomatic spinal stenosis. There are no published trials comparing other minimally invasive techniques (eg, laser-assisted discectomy) versus open discectomy, microdiscectomy, or nonsurgical therapy.In this case, there is little clinical documentation regarding prior treatment and no documentation of any prior surgical consultation. In addition, the medical literature does not support that laser spine surgery would provide any benefit over other approaches (open surgery, microdiscectomy) if surgical intervention is medically necessary. The submitted records do not detail extenuating circumstances to support laser spine surgery over other possible approaches. Under these circumstances, the requested consultation with a qualified laser spine surgical to determine if laser spine surgery is appropriate is not medically necessary for treatment of the patients medical condition at this time.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 family 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: Overturned

Findings:  The physician reviewer found that The patient has requested authorization and coverage for magnetic resonance imaging (MRI) of the brain (CPT 70553). Dizziness is a nonspecific term often used by patients to describe symptoms. Furman and colleagues explain that vertigo is one type of dizziness, and that other symptoms that patients may identify as dizziness include presyncopal faintness, disequilibrium, and nonspecific or ill-defined light-headedness. The authors further note that patients often experience vertigo as an illusion of motion, the most common being a spinning sensation, although vertigo may also be a sense of swaying or tilting. Differential diagnosis of vertigo includes peripheral vestibular causes such as acute labyrinthitis, acute vestibular neuronitis, benign positional vertigo, or Meniere's disease, central vestibular causes such as vestibular schwannoma, intracranial tumor, stroke, migraine, or multiple sclerosis, and other conditions such as drug-induced or psychological. The authors note that neuroimaging may be indicated if the examination is not entirely consistent with a peripheral lesion, if there are prominent risk factors for stroke, if there are neurologic signs or symptoms, if the patient cannot walk, or if there is a new headache accompanying the vertigo. In neuroimaging for a diagnosis of vertigo, MRI is superior to computed tomography due to its superior ability to visualize the posterior fossa. In this case, the patient initially presented with recurrent episodes of dizziness and lightheadedness accompanied by other symptoms including tinnitus, subjective hearing loss, loss of balance, and headaches. In this clinical setting, neuroimaging with an MRI of the brain is indicated due to the presence of other neurologic symptoms for a possible diagnosis of vertigo. Therefore, MRI of the brain (CPT 70553) is medically necessary for the evaluation of this patient. Final Result: The reviewer determined that the requested service is medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a five-year-old male enrollee has requested for occupational therapy, speech therapy and applied behavioral analysis (ABA) therapy for treatment of the enrollees autism. Findings:  Two physician reviewers found that ABA therapy is an intensive therapeutic modality that has been available for the treatment of children with autistic disorders for some time. It is considered a health care service in the treatment of autism spectrum disorders. Several recent publications have suggested that ABA therapy can result in positive gains for autistic children.Occupational therapy has been widely utilized to improve motor skills in autistic children. The peer-reviewed papers referenced above discuss occupational therapy in autistic and developmentally disabled children. Occupational therapy is well established as beneficial and is often integral to the habilitation of autistic children.Speech therapy is also a well-accepted modality for children with autism and can play a vital role in helping improve communication skills in this patient population. A treatment plan with specific goals must be delineated and written, and progress must be measured using appropriate metrics on a relatively frequent basis.