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

The parent of a 16-year-old male enrollee has requested psychiatric residential treatment services for the treatment of the enrollees behavioral health problems. Findings:  The physician reviewer found that the submitted medical documentation does not demonstrate medical necessity for placement in a 24-hour sub-acute residential setting. The patient was described as low risk for dangerous behavior, displayed no mood or thought disturbance, experienced no episodes of aggressive behavior and was motivated for treatment. Thus, the patient did not meet the Child and Adolescent Level of Care Utilization System (CALOCUS) level of care criteria or the American Academy of Child and Adolescent Psychiatry (AACAP) Practice Parameters for oppositional defiant disorder (ODD). The practice guidelines for the treatment of ODD recommends the least restrictive treatment setting whenever safely possible and identifies day treatment and/or intensive community based and family interventions as preferable alternatives to residential placement.
Appeal type: Experimental/Investigational
Decision: Upheld

A 58-year-old male enrollee has requested a computed tomography scan of the coronary arteries for an evaluation of his possible coronary artery blockage. Findings:  Two physician reviewers found that the use of CT scan of the coronary arteries for the diagnosis and prognosis of coronary disease in this patient subset remains of unproven benefit. At this time, CT scan is not an accepted screening or confirmatory test in this patient population. Conventional screening tests within the standard of care include treadmill stress testing or coronary angiography. CT scan would not be able to accurately confirm or exclude important coronary obstruction. As such, it is not an accepted replacement for conventional screening methods.
Appeal type: Medical Necessity
Decision: Upheld

A 63-year-old male enrollee has requested for proton beam therapy for treatment of his prostate cancer. Findings:  The physician reviewer found that proton beam therapy is an effective way to heat prostate cancer with minimal side effects. IMRT is well studied as well, and the literature to date reveals equally effective survival with prostate cancer and diminished side effects compared to conventional radiation therapy. Furthermore, as of now, there is no published superiority of proton beam therapy over IMRT.
Appeal type: Medical Necessity
Decision: Upheld

The father of a five-year-old male enrollee requested authorization and coverage of a GlucoWatch. The Health Plan  denied the request indicating that the requested equipment is not medically necessary for treatment of the enrollees diabetes mellitus.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested equipment is not medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the peripheral bone density scan she received. Findings:  Two physician reviewers found that it is recommended that patients with anorexia nervosa should be assessed for bone density by dual-energy x-ray absorptiometry (DEXA) at diagnosis and at periodic intervals thereafter. Whereas both trabecular and cortical bone sites are affected in anorexia nervosa, the data overall suggest that in females, trabecular bone (such as the lumbar spine) are affected more severely than sites of predominantly cortical bone (such as the hip and whole body). This has been attributed to the profound estrogen deficiency that typically accompanies this disorder in addition to other hormonal and nutritional deficiencies. Therefore, the measurement of the lumbar spine is the most important. The bone density of the hip reflects the density of cortical bone. Medical management is based on the measurement of these two sites, which is the standard test, and not of the peripheral study that is done at the distal radius of the forearm. Thus, the peripheral bone density scan performed was not likely to be more effective than other modalities for 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 internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism and is 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 21-year-old female has requested coverage for residential treatment center services provided over a six week period for treatment of her behavioral health issues.  Findings:  The physician reviewer found that based on review of the available records, this patient has major depression, eating disorder, and multiple substance dependencies. The patients global assessment of functioning (GAF) was assessed to be 20-29, which is an indication for continuous 24-hour care. Further, the American Psychiatric Association (APA) treatment guidelines states that residential treatment 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. In addition, the APA notes that the standard of treatment is either an inpatient unit or residential treatment facility when lower levels of care have been tried and failed. In this case, outpatient treatments have been exhausted and ineffective. Therefore, residential treatment is in accordance with generally accepted standards of medical practice and clinically appropriate for the patients medical condition. All told, the services provided to this patient during the timeframe in question were medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 61-year-old woman who has sustained multiple fractures. Her primary physician has diagnosed osteoporosis. The patients DEXA scan of October 2003 reveals osteopenia. A request has been made for daily Forteo injections. The Health Plan has denied the request on the basis that Forteo is not medically indicated for treatment of the patients diagnosis.Based upon the information provided, the patient would benefit from treatment of osteopenia/osteoporosis. Fosamax is a medically reasonable and appropriate treatment for the patients condition. There is no scientific evidence that use of Forteo on a daily basis for two years would be more beneficial than the use of Fosamax. Furthermore, Forteo has not been shown to speed fracture healing. As such, I have determined that the requested medication 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 55-year-old female enrollee has requested Zomig 5mg for treatment of her migraines. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication.  The records indicate a diagnosis of migraine, with specific headache days per month.  This patients clinical presentation is consistent with chronic migraine, and this is commonly complicated by medication overuse.  In this case, the records suggest medication overuse, as indicated by the number of triptan tablets (Zomig plus Maxalt) requested.  Several classes of medications are used for the prevention of migraine, including beta blockers, anti-epileptic drugs, tricyclic antidepressants, and neurotoxins.  The current medical evidence does not support the requested medication in this clinical setting.  All told, Zomig 5mg is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for cochlear device implantation, with or without mastoidectomy. Findings:  The physician reviewer found that Current medical literature supports the use of cochlear implantation for single sided deafness as safe and effective. The U.S. Food and Drug Administration (FDA) notes a minimum age criterion of five years of age based on a lack of large clinical trials in young children with single sided deafness and cochlear implantation. In this case, the patient has a history of right-sided profound hearing loss. An MRI showed that the right vestibulocochlear nerve is diminutive, and the records noted a very small internal auditory canal. Given that this patient is below the FDA approved age for cochlear implantation secondary to unilateral hearing loss, and as the results of a cochlear implant may be poor due to the patients diminutive cochlear nerve and narrow internal auditory canal, the requested service is not medically indicated. Therefore, cochlear device implantation, with or without mastoidectomy, is not medically necessary for the treatment of this patient.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 otolaryngology  head and neck surgery with sub-specialty certification in neurotology 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 male diagnosed with type 1 diabetes mellitus and is currently using an insulin pump. The patient reported checking his blood glucose levels four to five times daily. He has experienced wide glycemic fluctuations from 58-370 mg/dL. His most recent body mass index was. Laboratory results showed a creatinine level, hemoglobin A1C level, and urine microalbumin/creatinine level. The patients current insulin pump is noted to have false delivery alarms, not deliver the correct dose of insulin, and is no longer in warranty. The patient has requested coverage for a Tandem T Slim X2 insulin pump. The Health Plan denied the request and reported the requested device was not medically necessary for the treatment of this patient. At issue in this case is whether the Tandem T Slim X2 insulin pump is medically necessary for the treatment of this patients medical condition. The American Diabetes Association (ADA) position statement on standards of medical care in diabetes states that continuous glucose monitoring (CGM) in conjunction with intensive insulin regimens can be a useful tool to lower hemoglobin A1C in selected adults with type 1 diabetes. Hybrid closed-loop insulin delivery improves glucose control while reducing the risk of hypoglycemia across a wide age range in patients with sub-optimally controlled type one diabetes and was also demonstrated to be safe. A randomized crossover trial comparing day-and-night closed-loop insulin delivery with usual pump therapy in patients with controlled type one diabetes as defined as a hemoglobin A1C less than 7.5%, compared with usual pump therapy, closed-loop delivery reduced hypoglycemia. A trial to evaluate in-home use of the hybrid closed-loop insulin delivery system over three months in type one diabetes showed a significant decrease in the time patients spent in hypoglycemia. The patient has fluctuating blood glucose levels along with hypoglycemia. The Tandem T slim insulin pump along with CGM has the capability of suspending insulin delivery to avoid hypoglycemia. Therefore, the request for a Tandem T Slim X2 insulin pump is medically necessary for the treatment of this patient.  Final Result: The reviewer determined that the requested device 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 diabetes, endocrinology, and metabolism 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 comprehensive breast cancer panel genetic testing for evaluation of her medical condition. Findings: Two reviewers found that the current medical evidence supports the requested services in this patients case.  Multigene panel testing is recommended by the National Comprehensive Cancer Network Guidelines for individuals at risk for genetic mutations. This patient already underwent BRCA1 and BRCA2 testing and was found to be negative.  Given her personal and family history, more complex panel testing would be indicated to determine risk for future cancers.  In sum, the superior efficacy of the requested comprehensive breast cancer panel genetic testing has been established.   Final Result: Two reviewers determined that the requested services are 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: All three reviewers are board certified in internal medicine with sub-specialty certification in medical oncology 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: Upheld

Nature of Statutory Criteria/Case Summary: A 44-year-old female enrollee has requested authorization and coverage for splanchnic nerve blocks. This patients records do not document that all primary pharmacological treatments and non-pharmacological treatment options have been exhausted. Specifically, there is no mention of behavior therapy despite much research to support its use. Also, not all non-opioid medications have been optimized or tried. Moreover, splanchnic nerve blocks for the treatment of non-malignant or non-pancreatic abdominal pain have limited research to support its use. For these reasons, the requested splanchnic nerve blocks are not medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in anesthesiology 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: Medical Necessity
Decision: Overturned

A 36-year-old male enrollee requested authorization and coverage of a Septoplasty for the treatment of sleep apnea.  The Health Plan denied the enrollees request indicating that the requested treatment is not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer overturned the health plans denial on the basis that the requested procedure is medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for custom foot orthotics ordered and casted on 8/12/20.Orthotics have long been considered standard of care for the treatment of proximal heel pain/plantar fasciitis, as well as peroneal tendinitis. Customized orthotic devices control the foot and keep it in a neutral position, reducing stress and strain to the medial arch, origin of the plantar fascia at the heel, as well as peroneal tendons. Historically, custom orthotics are more supportive and can be more controlling to help alleviate heel pain, arch pain, and peroneal tendon pain. Customized orthotics, besides fitting better, are usually fabricated with a firmer functional material to provide superior support and control. In this case, the patient states that he has failed treatment with over-the-counter orthotics. The submitted documentation also shows that the patient has tried and failed low dye foot strapping. Therefore, the custom foot orthotics ordered and casted on 8/12/20 were medically necessary for the treatment of this patients medical condition.Final Result: The reviewer determined that the requested equipment is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is a licensed D.P.M., board certified in podiatry, 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 45-year-old male who has facial, hand, and feet hyperhidrosis. The patient has requested authorization and coverage for a bilateral thoracoscopic sympathectomy. The Health Plan has denied the patients request on the basis that thoracoscopic sympathectomy is not medically necessary.The medical necessity of the requested procedure has not been established. There is no evidence that the patient has experienced skin maceration. In addition, the risk of Horners syndrome is high for this patient. As such, the risks of the requested procedure outweigh the potential benefits. Therefore, I have determined that the requested procedure is not medically necessary for the treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

A 63-year-old female enrollee has requested adult mental health intensive outpatient treatment services for treatment of her bipolar affective disorder.  Findings:  The physician reviewer found the submitted documentation fails to demonstrate the medical necessity of the services at issue.  The current medical evidence does not support the services at issue in this clinical setting.  Per the clinical notes, there was no overt deterioration in functioning.  This enrollee was demonstrating anxiety that one would expect from an individual coping with a medical illness and situational problems.  This is traditionally treated in an outpatient mental health setting or brief, such as two weeks, of intensive outpatient treatment for stabilization with the goal of immediate return to outpatient treatment.  All told, adult mental health intensive outpatient treatment services is not medically indicated for the treatment of this enrollee.
Appeal type: Medical Necessity
Decision: Overturned

The patient has been diagnosed with osteoarthritis of the knees. The patient received the fifth Supartz injection in both knees. In the application for independent medical review, the patient reported receiving Supartz injections to her knees for the previous eight years with relief. The patient has requested authorization and coverage for Supartz injections in both knees. The Health Plan denied the request and reported the requested services are not medically necessary for the treatment of this patient. At issue in this case is whether Supartz injections in both knees are medically necessary for the treatment of the patients medical condition. Review of the current medical literature pertaining to viscosupplementation reveals mixed results.  Although viscosupplementation may relieve knee pain in some patients with osteoarthritis, it is unknown which patients will benefit. Viscosupplementation can only be recommended in patients with a history of lasting benefit from prior injections and in carefully selected cases where the options are limited. Researchers found that viscosupplementation increased functional scores in patients with severe osteoarthritis of the knee, especially within three months of injection. In this case, the patient reported lasting benefit from prior Supartz injections over the last eight years. Furthermore, the options are limited, with the alternative being total knee arthroplasties. The medical evidence supports the requested services in this clinical setting. Therefore, Supartz injections in both knees are medically necessary for the 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 orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a four-year-old female enrollee has requested 30 hours per week of applied behavior analysis (ABA) therapy for treatment of the enrollees autism. Findings:  The physician reviewer found that ABA therapy is supported as superior to special education or standardized care in improving the outcome in patients with autism. Given the current standards of practice, the requested ABA services should be provided at a frequency of 30 hours per week. The patient should begin with the requested 30 hours of ABA therapy with evaluations every 6 months, in order to assess the necessity of the number of hours required to adequately address this patients individual needs. In sum, the requested services have been demonstrated to be medically necessary in this instance and should be approved.
Appeal type: Medical Necessity
Decision: Overturned

A 36-year-old female has requested a duodenal switch bariatric procedure for treatment of morbid obesity.  Findings:  The physician reviewer found that the evidence shows that duodenal switch has a superior long-term outcome when compared to Roux-en-Y gastric bypass.