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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for ARUP Skeletal Dysplasia Panel, Sequencing and Deletion/Duplication. Findings:  Two out of three physician reviewers found that determining the etiology of skeletal dysplasia is critical in establishing the risk to future pregnancies. Assessment of radiographic findings, molecular analysis and pathology specimens enables postnatal assignment to a specific group within the Nosology and Classification of Genetic Skeletal Disorders system. In this case, tissue should be referred for DNA extraction for microarray analysis, mutation analysis for a specific gene disorder when a specific diagnosis is suspected, as well as gene panel testing. Therefore, the ARUP Skeletal Dysplasia Panel, Sequencing and Deletion/Duplication is likely to be more beneficial for evaluation of the patients condition than any available standard therapy. One reviewer found the testing is not llikely to be more beneficial for evaluation of the patients condition than any available standard therapy because the NCBI Genetic Testing Registry notes that the clinical validity and clinical utility of the test has yet to be supported by adequate current medical literature.Final Result: Two reviewers determined that the requested testing is 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 and 2 are board certified in obstetrics and gynecology and reviewer 3 is board certified in obstetrics and gynecology with subspecialty certification in maternal-fetal medicine, and all 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 48-year-old female enrollee has requested for the prescription medication Humatrope for treatment of her pituitary disorder.  Findings:  The physician reviewer found that there are issues other than growth hormone deficiency, such as hypothyroid state and poor nutrition, that can cause a low IGF1.  Although this patient may have growth hormone deficiency, it has not been established by the tests and other information provided for review.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 12-year-old male enrollee has requested 2 hours per week of occupational therapy for treatment of the enrollees autism.   Findings:  The physician reviewer found that the scientific literature is replete with studies supporting the use of occupational therapy (OT) to improve function in autistic patients. Case-Smith and Arbesman evaluated six categories for the need of occupational therapy and found that across all domains studied, OT considerably helped the patient. The authors further noted that OT usually addresses deficits such as poor trunk stability, reduced muscle tone, poor endurance, tactile defensiveness, proprioceptive processing issues, and cognitive impairments that are associated with motor skills development in children with autism.  Moreover, the American Academy of Neurology (AAN) guidelines for autism developed in 2000 states, The immediate and long-term evaluation and monitoring of autistic individuals requires a comprehensive multidisciplinary approach, and can include one or more of the following professionals: psychologists, neurologists, speechlanguage pathologists and audiologists, pediatricians, child psychiatrists, occupational therapists, and physical therapists, as well as educators and special educators. Based on the data available, the standard of care for this patient is to provide the requested OT services as OT is an appropriate modality in this setting and therefore clinically indicated.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: a 57-year-old female with diagnoses of menopausal and female climacteric states, and hypothyroidism. Findings:  The physician reviewer found that the patient has a family history of ovarian and breast cancers. The patient had a pelvic ultrasound in 2015, which revealed an intact uterus and intact ovaries. Her most recent thyroid stimulating hormone (TSH) was performed in December 2018, and was suppressed at 0.02. The treatment plan included levothyroxine 125mcg daily and Cytomel 25mcg daily. Additional medications have included T4/T3, estrogen, progesterone, dehydroepiandrosterone (DHEA), testosterone, and growth hormone therapies. She underwent laboratory testing in March 2018 to monitor the hormones estrogen, progesterone, TSH, free T3 and T4, DHEA, as well as vitamin and nutrient levelsThe Endocrine Society guideline does not support DHEA replacement therapy for this patient since use of DHEA sulfate is not recommended by the Endocrine Society guidelines. In addition, testosterone replacement therapies in post-menopausal women are not approved by the U.S. Food and Drug Administration (FDA) because of limited clinical trial data demonstrating improved efficacy compared with placebo, and due to concerns about long-term safety. Further, the Endocrine Society does not recommend the general use of testosterone other than for hypoactive sexual desire disorder. There is no current indication for vitamin and nutrient level testing, as there is no report of vitamin deficiencies. The patient has a diagnosis of post-surgical hypothyroidism (E03.9). Thus, thyroid function tests need to be performed to monitor the patient while she remains on T4/T3 supplementation (Jonklaas, et al). Given this support, thyroid function tests are medically necessary for the patients diagnosis of hypothyroidism E03.9 (TSH, free T3 and T4). However, laboratory tests to monitor hormone levels in the blood: N95.1 (estrogen and progesterone), R53.83/E27.40 (DHEA-S), and E63.8 (nutrient levels), are not medically necessary. Final Result: The reviewer determined that the requested services are partially medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld for N95.1 (estrogen and progesterone), R53.83/E27.40 (DHEA-S), and E63.8 (nutrient levels). The Health Plans denial should be overturned for E03.9 (TSH, free T3 and T4).
Appeal type: Medical Necessity
Decision: Upheld

The parent of a 15-year-old female enrollee has requested residential treatment center services for the treatment of the enrollees anxiety disorder, not otherwise specified, identity problem and oppositional defiant disorder. Findings:  The physician reviewer found that at the time of admission, the patient did have psychiatric symptoms. However, a need for continued residential care was not established as of the date in question. The patient was not at risk of harm to self or others and did not require 24/7 professional monitoring beyond the last authorized date of service. She was not psychotic, and there was no suggestion that she would decompensate if she was treated at a lesser level of care. Although she had harmed herself in the past, she did not generally appear to be a current risk for such harm. She was described as alert and oriented and denied hallucinations, delusions, and suicidal and homicidal thoughts. The patient was stable for transfer to a less intensive level of care. Thus, she did not require treatment at a residential facility. She could have been safely and effectively treated at a lesser level of care.
Appeal type: Medical Necessity
Decision: Overturned

The patients parent has requested authorization and coverage for six months of dual diagnosis residential treatment center (RTC) in a secure facility. The American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists Child and Adolescent Level of Care Utilization System (CALOCUS) provides a reliable framework for determining the appropriate level of care for adolescents needing mental health treatment. Using CALOCUS, providers score patients on a scale of 1-5 using a six-pronged Dimensional Rating System. The six dimensions include: (1) risk of harm; (2) functional status; (3) developmental, medical, substance use and psychiatric comorbidity; (4) recovery environment (a. stressors and b. supports); (5) treatment and recovery history; and (6) engagement. The composite score is then used to determine the level of care needed. Applying the CALOCUS framework, this patient meets the criteria for six month of dual diagnosis RTC in a secure facility. These findings give the patient a composite score which is consistent with Level Five medically monitored residence based services. Per CALOCUS, due to the extreme risk of harm, the recommended level of care is a Level Six medically managed residence based services. All told, the requested six months of dual diagnosis RTC in a secure facility is medically necessary for treatment of this patient. 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 with subspecialty certification in child and adolescent psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 43-year-old male with a history dating to summer 2002. At that time, the patient indicates he visited Connecticut and acquired Lyme disease. He did not initially have an erythema migrans rash or other symptomatology until a few months later. He does not recall a tick bite while he was in Connecticut. His symptoms over the last two years include muscle twitching, PACs, fatigue, tremors, eye pain, and mental fog. Subjectively he indicates his symptoms have improved with extended antibiotic therapy.  A neurology consultation did not reveal a diagnosis for the patients presentation. Physical exams by three physicians did not show any joint effusions, limited range of motion in the joints or any objective neurologic findings. Laboratory evaluation includes a chemistry panel, CBC, Lyme Antibody, and Lyme Western Blot. Other studies include MRI of the brain, CT scan of the abdomen and pelvis, and lumbar puncture. The patients Lyme serology and CSF fluid analysis is negative. Other imaging is unrevealing. The patient has received multiple courses of various oral antibiotics with some subjective improvement, but no objective clinical difference. The patient is seeking additional long-term antimicrobial therapy.The patient has little evidence of active Lyme disease  either early or late stage. The diagnosis of neuroborreliosis is supported with a positive CSF, positive Western Blot and objective neurological findings. Lyme arthritis is diagnosed with a positive synovial fluid analysis, positive Western Blot, and objective physical examination findings. This patient meets none of the above criteria. Furthermore, there are no double blind, placebo-controlled trials published in peer-reviewed journals demonstrating the efficacy of prolonged antimicrobial therapy beyond four weeks or repeated therapy whether provided intravenously or orally. Moreover, there are studies in the peer-reviewed literature (see citations above) demonstrating no benefit to extended antimicrobial therapy in the treatment of Lyme disease.Based upon the information set forth above, I have determined the requested therapy is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 58-year-old female with a history of basal cell carcinoma. She currently has three relatively small, superficial lesions (1cm by 0.5cm by 0.1cm, 0.8cm by 0.6cm by 0.1cm, and 0.6 by 0.4 by 0.1cm) located on the upper back and shoulder. The patient requested consultation with a plastic surgeon for removal of the lesions. The Health Plan denied her request based upon a determination that plastic surgery consultation is not medically necessary.The patient reports she had several facial lesions treated by a plastic surgeon.  She now has three relatively small lesions located on less cosmetically sensitive parts of the body.  The management of lesions this size is not complex; the surgical treatment of small basal cell carcinomas is certainly within the purview of a dermatologist. The anticipated wounds can be readily closed without undermining or flap closures. Specialized plastic surgery is not medically indicated. Therefore, I have determined the requested services are not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for Nutropin AQ Nuspin 10 mg/2 mL pen. The patients height is more than 2.5 standard deviations below the mean for age and gender. In addition, all known systemic causes of short stature have been ruled out. Based on the patients bone age and height assessment, their estimated final adult height is approximately 57 inches. This height prediction is more than 2.5 standard deviations below the mean. The U.S. Food and Drug Administration (FDA) has approved a trial of growth hormone therapy in patients with idiopathic short stature who have an adult predicted height less than 59 inches. This patient meets FDA criteria for a trial of growth hormone therapy for idiopathic short stature. Thus, the requested Nutropin AQ Nuspin 10 mg/2 mL pen is supported as medically necessary for treatment of this patients medical condition. 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 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

A 55-year-old female enrollee has requested codeine/butalbital/aspirin/caffeine (Fiorinal with Codeine #3), quantity #90/30 days for treatment of her headaches. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication quantity.  The patient has a longstanding headache history and has been using the requested medication for at least four years.  However, no specific diagnosis is identified by the submitted records.  Further, details regarding headache characteristics, diagnosis and frequency were not reported.  Per the medical literature, patients with primary headaches such as migraine are prone to increase of headaches related to pain medication usage.  The use of opiates for more than eight days per month, or barbiturates more than five days per month has been associated with progression of headaches.  Per the current medical evidence, the use of barbiturates and opiates are not recommended for headache care.  Thus, the requested additional quantity of codeine/butalbital/aspirin/caffeine (Fiorinal with Codeine #3) is not medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested anterior optical coherence tomography for evaluation of her medical condition.   Findings:  Two physician reviewers found that the submitted documentation fails to demonstrate the superior efficacy of the services at issue.  In order to evaluate the angles of the eye in a glaucoma suspect, gonioscopy is generally performed.  The angles are graded as to how open or closed they are, and this is documented.  This determines potential future treatment of the patient.  Anterior segment optical coherence tomography can provide very high resolution images of the angles, which can help in this regard, but it is generally not performed if gonioscopy is done.  All told, the anterior optical coherence tomography was not likely to have been of greater benefit than other methods of evaluating this patient. 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:   All three reviewers are board certified in ophthalmology 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for non-invasive prenatal testing for evaluation of the enrollees second pregnancy. Findings:  The physician reviewer found that the American College of Obstetricians and Gynecologists (ACOG) recommend cell free DNA testing as a screening option for women at increased risk of fetal aneuploidy. ACOG defines this high risk population as women 35 years or older, fetuses with ultrasonographic findings indicative of an increased risk of aneuploidy, women with a history of trisomy affected offspring, a parent carrying a balanced Robertsonian translocation with an increased risk of trisomy 13 or trisomy 21, and women with positive first or second trimester screening test results. Since this patient is reportedly 36-years-old, the aneuploidy risk for this patient in this pregnancy warrants cell free DNA testing for aneuploidy. Thus, the requested non-invasive prenatal testing is supported as medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the requested testing is medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in obstetrics and gynecology with sub-specialty certification in maternal and fetal 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: Upheld

A 57-year-old female enrollee requested authorization and coverage of a repeat Dexa scan. The Health Plan denied the request indicating that the requested Dexa scan is not medically necessary for evaluation of the enrollees osteoporosis.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested Dexa scan is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested Botox injections for treatment of her medical condition.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  This patient has diagnoses of cluster and migraine headache per the medical records.  There is no indication of headache frequency or prior medications other than verapamil and indomethacin.  Data regarding Botox for headaches shows good success at doses of 155 to 195 units for patients with chronic migraine.  However, data regarding treatment for cluster headaches is more mixed, and typically when used for this diagnosis it has been after trials of several standard preventive medications such as lithium, topiramate and valproic acid, and more typically at doses as used for chronic migraine.  The provided records do not support the medical necessity of Botox treatment for this patients condition.  All told, the requested Botox injections are not medically indicated for the treatment of this patient. 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 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

A 20-year-old male enrollee has requested residential treatment services for the treatment of his chemical dependency. Findings:  The physician reviewer found that this patient presents with a diagnosis of cannabis abuse with reported use of two to three  times per week and he also reports medical use for insomnia. From the records, his functional impairment appears mild as he was working and attending school. No major co-morbidity issues were present and his sleep disturbance was treated with Rozerem. There was no noted self-harm or aggressive behavior, nor did the patient appear to be at risk for these behaviors. The patient described conflict with his mother which appeared to be moderate. During treatment, he displayed hesitation in accepting cannabis diagnosis. Overall, medical necessity for treatment in a residential 24-hour setting is not established based on the medical documentation and in accordance with the Level of Care Utilization System (LOCUS) criteria. Further, the American Psychiatric Association (APA) treatment guidelines recommend therapy in the least restrictive setting possible; this patient did not require 24-hour treatment services, and could have been safely and appropriately treated at a lower level of care.
Appeal type: Medical Necessity
Decision: Overturned

A 47-year-old female enrollee has requested for transcranial magnetic stimulation (TMS) therapy for treatment of for depression and anxiety.  Findings:  The physician reviewer found that TMS therapy has an indication for patients with treatment resistant depression with the failure of 1 pharmacologic agent. This patient had not responded to several conventional therapies including numerous pharmacologic agents. For these reasons, the TMS therapy has been established as medically necessary as a means to alleviate her severe treatment resistant depression.
Appeal type: Medical Necessity
Decision: Upheld

A 56-year-old male enrollee has requested authorization and coverage for the medication Celebrex for treatment of left shoulder pain. Reviewer's Findings:  The physician reviewer found Celebrex is a second generation NSAID that is generally not clinically indicated absent the failure of the more commonly prescribed NSAIDs taken in combination with a proton pump inhibitor. Such a trial would be reasonable for this patient before the long-term use of Celebrex is initiated. It does not appear that has occurred, therefore the use of Celebrex cannot be recommended.