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

A 44-year-old female enrollee has requested Botox injections for the treatment of her migraine headaches. Findings:  Three physician reviewers found that this case involves a patient with severe headaches refractory to multiple standard first-line therapies for migraine headaches. In addition, she has a contraindication to other standard first-line therapies given her co-morbidity of asthma. Although Botox is not a first-line therapy for headaches, there is ample literature demonstrating its use for chronic headaches and it is a very good second-line therapy. Since this patient has failed multiple attempts with other more standard medications, the medical use of Botox in this particular case is indicated.
Appeal type: Medical Necessity
Decision: Upheld

The parent of 16-year-old female enrollee has requested for psychiatric residential treatment services for treatment of the enrollees behavioral health problems. Findings:  The physician reviewer found that though the patient suffers from Bulimia, it is not quite clear from the notes included just how often she was actively restricting her calories or binging. In addition, the patient was clearly preoccupied with her own appearance and sexuality and was quite given to angry acting out when limits were set with her at home. To this extent, some of her claim of wanting to weigh as little as 90 pounds appears to be anger-fueled bravado and not genuinely reflective of the extent of her eating disorder per se.  In conjunction with some of the previously cited notes, one might conclude that she demonstrates a fair amount of Histrionic and Narcissistic pathology. That said, it has not been established that the optimal approach for the patient was or is residential treatment. In fact, one can make a cogent argument for the patient being held more firmly to outpatient treatment so as not to reinforce this sort of acting out. Family therapy could have been integrated into intensive outpatient therapy, and could have been more successful in the long run, having to occur in the home environment, which seems to trigger so much for the patient. As for her medications, these could have been equally efficacious if administered via intensive outpatient treatment.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for partial hospitalization program services. The Health Plan has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees anxiety; bipolar disorder; substance abuse; alcohol abuse; depression; and stress disorder.At issue in this case is whether the requested partial hospitalization program services are medically necessary for treatment of the enrollees behavioral health condition.The American Psychiatric Association treatment guidelines for Substance Use Disorders recommends that care higher than outpatient is indicated for patients who do not meet the clinical criteria for hospitalization but whose lives and social interactions have come to focus predominantly on substance use.. lack sufficient social and vocational skills and drug-free social supports to maintain abstinence in an outpatient setting.The patient requires safe and stable living environments in order to develop their recovery skills, thus qualifying for ASAM Level III treatment at least i.e. similar to what patient received at the facility. Given the severity of the patients illness (daily blackouts,) her high relapse risk and consequent risk of immediate harm, the partial hospitalization program is in accordance with generally accepted standards of medical practice; clinically appropriate for the patient's illness, and is therefore medically necessary.Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in 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

The patient is a 54-year-old male who underwent removal of a 5mm prolactinoma in 1999.  In 2003, the patient was subsequently found to have normal pituitary function except for HPA axis, which was not noted to be tested. He was obese prior to surgery and gained substantial additional weight over the next several years. In May 2003, based on a low normal IGF-1, an endocrinologist suggested growth hormone (GH) replacement. A preoperative test (arginine) was performed with a limited response (increase) in GH levels. On the basis of this test the patient was diagnosed with adult growth hormone deficiency and GH replacement therapy was recommended. The Health Plan has denied authorization for Genotropin GH therapy on the basis that it is not medically necessary.The patients prolactinoma was small; its removal did not lead to hypopituitarism. The patients data indicates normal pituitary function, as far as was tested. IGF-1, even if low, is not an adequate test of GH deficiency unless it is very low and even then it is only suggestive. The patients level was minimally low or low normal, which is common in obesity. In addition, an isolated arginine stimulation test is not recognized as adequate to diagnose adult growth hormone deficiency. Furthermore, obesity, in and of itself, does not indicate decreased muscle mass. To document adult growth hormone deficiency in this patient an insulin tolerance test and/or a combined arginine/GHRH test would be necessary. At this time, there is no evidence that Genotropin GH therapy is medically indicated for this patient.Based upon the information set forth above, I have determined that the requested therapy is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

A 71-year-old female enrollee has requested for Prolia 60mg for treatment of her osteopenia/osteoporosis. Findings:  The physician reviewer found that a recent article states, Given the absence of long-term safety data and the availability of other agents, denosumab [Prolia] is not recommended for osteoporosis prevention. The U.S. Food and Drug Administration (FDA) and the European Commission approved denosumab for the treatment of postmenopausal women with osteoporosis at high risk for fracture (history of osteoporotic fracture, multiple risk factors for fracture) or patients who have failed or are intolerant of other available osteoporosis therapies. (Rosen)As noted above, the patient currently presents with osteopenia. Moreover, there is no indication in the office notes that the patient has been unable to tolerate Boniva or that Boniva has been ineffective. As such, the patient does not meet clinical indications for the use of Prolia.
Appeal type: Medical Necessity
Decision: Overturned

The parents of a three-year-old male enrollee have requested for ABA therapy for treatment of his global developmental delays. Findings:  The physician reviewer found that the present treatment of choice and the only well-documented successful therapy for autism is ABA therapy. This treatment has been shown to result both in gains in IQ scores as well as improvements in functioning across language, social and behavioral adaptive domains. The studies by Sallows et al. and Howard demonstrated improvements in IQ scores following ABA treatment as compared with age and IQ matched controls. Although progress may be slower in patients with lower initial IQs, studies have shown improvements with ABA across a range of initial IQ scores, and there is no cut off point for pre-treatment IQ below which ABA has not been shown to be beneficial. This patient has made limited but definite progress with the intensive ABA home program.
Appeal type: Medical Necessity
Decision: Overturned

A 19-year-old female enrollee has requested eating disorder residential treatment center services for treatment of her anorexia nervosa. Findings:  The physician reviewer found that modern psychiatric practice aims to place patients in the least restrictive treatment setting.  In general, community intervention settings offer optimization of treatment gains.  However, episodic placement in more restrictive settings is often clinically appropriate.  In this case, the patient demonstrated a steady decline from her previous admission to the acute unit of an academic tertiary medical center.  In the month and year specified, the records demonstrated that the patient was failing the outpatient venue and experiencing functional impairment across multiple domains.  On the date indicated, the patient weighed just over 65 pounds, and this correlated with a body mass index of 12.8.  She was amenorrheic, depressed, anxious and cognitively impaired with negative schemas and fear of weight gain.  In the absence of an intensive course of treatment in a supervised setting, a poor outcome was likely.  After reviewing the medical documentation, the disputed services were for active treatment delivered in accordance with an individual treatment plan.  Further, the services were reasonably expected to improve the patients condition and prevent a more serious episode of illness.  All told, eating disorder residential treatment center services provided from the time period specified were medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested Daklinza and Sovaldi for treatment of her 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 treatment-naive genotype 3 patients, 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 cure rate of 97%. In this case, the patient is ineligible for interferon-based alternatives due to anxiety. In addition, 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 supported as 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 authorization and coverage for methadone HCL 5 mg tablets for treatment of the enrollees back and lower extremity pain. Findings:  The physician reviewer found that there is a lack of support for the requested medication in this clinical setting. Guidelines offer very specific requirements for the ongoing use of opiate pain medication to treat chronic pain. Methadone is an opioid analgesic recommended after a trial of a first line oral analgesic has failed. Opioids are generally not recommended as first line therapy. However, when used, clinicians should closely monitor patients for loss of response, adverse effects or aberrant behavior, and revise the treatment plan accordingly. Moreover, it is recommended that urine drug testing may be used as a tool to monitor for aberrant behavior or drug misuse. Opioids should be tapered when patient safety risks are identified. Recommendations state the lowest possible dose be used as well as ongoing review and documentation of pain relief, functional status, appropriate medication use and its side effects. The guidelines recommend that providers of opiate medication document the patients response to pain medication, including the duration of symptomatic relief, functional improvements, and the level of pain relief with the medications. In this patients case, it is unclear from the documentation if there was a decrease in the level of pain from one visit to the next. In addition, there was no noted functional improvement or improved pain noted during the duration of the prescription for morphine. Peer reviewed guidelines state that pain assessment should include current pain, the least reported pain over the period since last assessment, average pain, intensity of pain after taking the opioid, how long it takes for pain relief and how long pain relief lasts. Satisfactory response to treatment may be indicated by the patients decreased pain, increased level of function, or improved quality of life. While the medical records report chronic pain, the records do not support failure of first line opioids. The submitted records also do not show that necessary guidelines, as described in the medical literature, have been met. Therefore, congruent with peer reviewed guidelines, methadone HCL 5 mg tablets are not 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 in neurology with sub-specialty certification in pain 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: Experimental/Investigational
Decision: Upheld

A 54-year-old male enrollee requested authorization and coverage of gastric bypass with duodenal switch. The Health Plan denied the request indicating that the requested procedure is considered experimental for the treatment of the enrollees morbid obesity.Three physician reviewers performed an experimental/investigational Independent Medical Review. Two physician reviewers concluded that the requested procedure is not likely to be more beneficial for the treatment of the enrollee's medical condition than any available standard therapy. One physician reviewer concluded that the requested procedure is likely to be more beneficial for the treatment of the enrollee's medical condition than any available standard therapy. Because two of the three physician reviewers concluded that the requested surgery is not likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy, the Health Plans denial has been upheld.
Appeal type: Experimental/Investigational
Decision: Overturned

A 54-year-old female enrollee has requested cryosurgical ablation for the treatment of her benign fibroadenoma. Findings:  Two physician reviewers found that there is literature to support the use of cryoablation for symptomatic breast fibroadenoma. Clinical studies support the validity of ultrasound-guided cryoablation as a treatment option for this particular patient. According to the American Society of Breast Surgeons, the following criteria establish a patient as a potential candidate for cryoablation of a fibroadenoma: the lesion must be sonographically visible, the diagnosis of fibroadenoma must be confirmed histologically and the lesion should be less than 4 cm in largest diameter.  This patient met these criteria. Cryoablation was medically indicated and appropriate for this patients care.
Appeal type: Medical Necessity
Decision: Upheld

A 19-year-old male enrollee has requested Adderall for treatment of his bipolar disorder.  Findings:  The physician reviewer found that there are no indications for treating this patient with Adderall. The records do not support a diagnosis of bipolar disorder. This patient has a presumed diagnosis of bipolar disorder, which was given after one visit in which the patient did not offer much communication. In addition, this patient has a substance abuse problem with cannabis, thus prescribing Adderall which has potential for abuse, is contraindicated. The provider appropriately prescribed a very small dosage of Risperdal, only 0.5 mg, which would be safe without risk of gynecomastia in this young patient. However, the use of Adderall in the absence of a clinically approved indication is not supported as medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Rituxan (rituximab). This patients records document that the patient has been unable to tolerate standard therapy for systemic lupus erythematosus (SLE) with mycophenolate mofetil. In addition, the patient and provider are planning to avoid the use of cyclophosphamide due to the potential for the side effect of infertility. According to the American College of Rheumatology (ACR) guidelines for the screening, treatment, and management of patients with SLE, Rituxan is an appropriate therapy for the treatment of patients with SLE, especially given the patients plans childbearing age and desire to preserve fertility. On review of this patients records and the ACR guidelines, Rituxan is indicated for this patient as a third-line treatment option for the management of SLE, especially given the patients decision to avoid the risk of infertility associated with cyclophosphamide. Therefore, the requested Rituxan (rituximab) is medically necessary for treatment of this patient.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 reviewer is board certified in internal medicine with subspecialty certification in rheumatology 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 31-year-old female enrollee has requested biofeedback and hyperbaric oxygen therapy for the treatment of her headache. Findings:  Two physician reviewers found that biofeedback has generally been accepted as having efficacy in chronic migraine and tension-type headache (Nestoriuc, et al.). In this case, there is no documented diagnosis of either migraine headache or tension headache, and in fact, the etiology of the patient's headache is not documented. In addition, the patient had tried some prophylactic medications but not all groups of medications with efficacy in chronic headache have been tried, most notably the beta blockers. Further medication trials were warranted as it is likely that these may have been beneficial. Given the current diagnosis, it is not likely that the biofeedback would be more beneficial than standard treatments for the patient's condition. Oxygen has been demonstrated to be efficacious in cluster headaches only. Hyperbaric oxygen has been demonstrated to have no greater efficacy as compared to high flow oxygen alone in cluster headaches (Nilsson, et al.). This patient does not carry the diagnosis of cluster headaches and does not have any of the typical vasomotor symptoms typical of paroxysmal hemi-cranial headaches. Standard therapies to treat this patients symptoms include trials of different prophylactic agents. Such therapies were likely to have greater efficacy in this case than hyperbaric oxygen therapy.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 46-year-old female who has been using CPAP in the treatment of obstructive sleep apnea. A polysomonography performed in March 2005 revealed mild obstructive sleep apnea (OSA) with an AHI of 10 and an oxygen saturation nadir of 87%. It was also noted at that time that the patients Epworth Sleepiness Scale score was 8/24. The patients height is stated to be 55 with a weight of 208 pounds. It would appear that the patient is not tolerating or satisfied with the use of CPAP since surgical consultation was sought for treatment of OSA. She was noted on examination in July 2005 to have inferior turbinate hypertrophy, a light tongue tie, large base of tongue and a long low slung palate. Inferior turbinate reduction and release of ankyloglossia were performed in August 2005. The treatment plan was to follow these procedures with UPPP and tongue base reduction. There was evidently a follow-up evaluation of the patients symptoms performed in September 2005. Repeat Epworth Sleepiness Scale was performed with a score of 14/24. The patient reports that she is tired during the day, frequently has headaches, has difficulty concentrating, has fallen asleep while driving, has experienced excessive weight gain and has been depressed. Her medications are noted to include Wellbutrin, Cymbalta, Vivactil, Restasis, Soma and Norco. At issue in this case is whether laser-assisted UPPP and radiofrequency ablation of the base of the tongue are medically necessary for treatment of the patients medical condition.Though the patient meets medical necessity criteria for a UPPP procedure, it is not medically necessary for the procedure to be performed with laser assistance. The use of laser assistance is not likely to result in a superior clinical outcome. With regard to the other requested procedure, although multi-level surgeries for OSA have been found to be more efficacious than addressing only a single site, tongue base ablation with radiofrequency is not yet standard of care. The patient does meet medical necessity criteria for tongue base reduction without radiofrequency ablation. However, there is insufficient evidence demonstrating that radiofrequency ablation of the base of the tongue is more effective than traditional tongue base reduction. As such, the use of radiofrequency ablation in this clinical setting is not medically warranted.Based upon the information set forth above, I have determined that the requested procedures are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.