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

Nature of Statutory Criteria/Case Summary:  An enrollee has requested three-dimensional (3D) breast tomosynthesis for evaluation of her medical condition.  Three physician reviewers found that although there is a lack of long term studies demonstrating increased survival rates when tomosynthesis has been added to the usual screening mammography protocol the addition of the technique has gained worldwide popularity among providers due to an associated significant decrease in callbacks and increased detection of small cancers.  Thus, the addition of the technique is considered more beneficial for the patient than mammography alone. Final Result: Three reviewers determined that the diagnostic procedure at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: All three reviewers are board certified in diagnostic radiology 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: Urgent Care
Decision: Upheld

A 34-year-old male enrollee has requested emergency services for evaluation of his wound. Findings:  The physician reviewer found that review of the submitted clinical documentation fails to demonstrate that a prudent layperson would have sought immediate medical attention. In this case, the patient had undergone incision and drainage of an abdominal wall abscess. He had been evaluated since the initial procedure and his wound was cleaned and packed. The patient continued to return to the emergency department for wound care. On a specified date, the patient related that his pain was well-controlled and thereafter he denied any pain. In addition, there was also no evidence of fever or sudden change in the patients condition. The patients symptoms were not acute in onset and he had been advised to follow-up with his primary care provider. Therefore, the patients symptoms did not meet prudent layperson criteria for emergency care on both dates of service in dispute.
Appeal type: Medical Necessity
Decision: Upheld

A 42-year-old female has requested for physical therapy for treatment of her endometriosis. Findings:  The physician reviewer found that there is a lack of medical evidence to support this manual therapy for the treatment of abdominal or pelvic adhesions.  The only studies in this area are uncontrolled pilot studies which do not provide sufficient evidence of efficacy to justify physical therapy for this patients condition.
Appeal type: Medical Necessity
Decision: Overturned

A 25-year-old male has requested coverage for weekly mental health therapy treatment from a specific date and forward for treatment of his depression, anxiety, and panic disorder.  Findings:  The physician reviewer found that based on review of the available records, the patient continues to meet the American Psychiatric Association (APA) criteria for ongoing treatment given his poor functioning. The records indicate the patient has not completed all of his treatment goals, and his symptoms have not resolved or responded well to medication. The patient should receive services on a weekly basis to continue to make progress. All told, weekly psychotherapy is appropriate to treat the patients condition, consistent with good medical practice, and is therefore medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  The parent of an enrollee has requested residential treatment center services 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 services at issue.  The patient was not a threat to herself or others. She was medically stable. Although continuing to experience anxiety, her medication management did not require residential level of care. She was compliant with her treatment and meal plan.  She was learning communication skills and to identify triggers.  She did continue to demonstrate eating disorder behaviors.  However, she had improved and her treatment could have continued at a lower level of care.  All told, residential treatment center services were not and are not medically indicated for the treatment of this patient.  Final Result: The reviewer determined that the services at issue were not and are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: The reviewer is 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

A 35-year-old female enrollee has requested acute inpatient hospitalization for treatment of her schizoaffective disorder, personality diagnosis and migraine headaches. Findings:  The physician reviewer found that the acute inpatient hospitalization services provided during the said time frame were not medically necessary. The patients psychiatric status was non-acute and symptoms of depression and anxiety were chronic and enduring. While these symptoms impacted the patients ability to function and needed to be addressed, they did not place her at acute and imminent risk. The patient did not require 24-hour supervised care by a physician as medication adjustments could have occurred safely in a less intensive setting such as a partial hospital program. Further, daily observations by qualified staff in a partial hospital setting would have been clinically sufficient and would be considered standard practice. Although acute and intractable migraine activity is a disabling condition, its management falls under the pervue of neurology and/or internal medicine and is not considered standard practice in the management of bipolar disorder. Consultation with neurology and its management is necessary but did not require acute inpatient care. Furthermore, a partial hospital setting provides the patient with consistent oversight and access to both pharmacotherapy as well as psychotherapy. Acquisition of coping skills, promotion of independent living skills and insight oriented therapies do not require an inpatient setting and can be provided on both an outpatient basis as well as a partial hospital setting. According to Hirschfeld, Utility of psychosocial interventions has expanded. Family focused therapy in which weekly psychoeducation, communication enhancement training and problem solving skills training occur. A two year study found that combination of pharmacotherapy and family focused therapy found that post episode adjustment and medication adherence were enhanced, patients had fewer relapses and longer survival intervals. In sum, the patients symptoms required ongoing management and the provision of these services could have been accomplished in a less intensive setting. Therefore, based on the documentation provided, coupled with relevant peer-reviewed medical literature and current practice guidelines, the services at issue were not medically necessary.daches.
Appeal type: Medical Necessity
Decision: Overturned

Findings:  The physician reviewer found that The patient has requested authorization and coverage for Tyrvaya nasal solution (0.03 mg/actuation). The U.S. Food and Drug Administration (FDA) approves the use of Tyrvaya (generic name varenicline solution) for the treatment of the signs and symptoms of dry eye disease. Wirta and colleagues report that OC-01 (varenicline) nasal spray is well tolerated and has a clinically meaningful effect on signs and symptoms of dry eye disease. Likewise, Quiroz-Mercado and colleagues report that OC-01 (varenicline solution) nasal spray improved tear production in patients with dry eye disease over a long-term (12-week) period. In this case, given that this patient with dry eye syndrome has tried multiple therapies including anti-inflammatory medications without significant improvement and experienced symptomatic relief with Tyrvaya, the requested medication is medically indicated. Therefore, Tyrvaya nasal solution (0.03 mg/actuation) is medically necessary for the 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.
Appeal type: Experimental/Investigational
Decision: Upheld

A 32-year-old male enrollee has requested transcranial magnetic stimulation for treatment of his depression. Findings:  Two physician reviewers found that the literature supports the efficacy of transcranial magnetic stimulation. However, there is a lack of literature demonstrating that this modality is more effective than any currently available treatment. American Psychiatric Association guidelines indicate that there is inadequate information supporting the efficacy of transcranial magnetic stimulation to warrant its use in standard practice. In this particular case, there is no evidence that factors which adversely impact the outcome (such as comorbid conditions, substance abuse, noncompliance, psychosocial stressors or lack of supports) have been investigated. Addressing these variables is essential in attaining a successful outcome. All told, the data reviewed do not indicate that this treatment is more likely to be effective than any existing treatment for this patient.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a two-year-old female enrollee has requested continued neurological follow-up visits with a pediatric neurologist for treatment of the enrollees epilepsy. Findings:  The physician reviewer found that this patient had the onset of a generalized seizure at seven months of age. She subsequently has had at least nine generalized seizures and trials of three antiepileptic drugs.  She presently is incompletely controlled on Keppra.  Additionally, she has been diagnosed with a failure to thrive and microcephaly. Her problems are presently multifactorial.  A specific common etiology to unify her treatment has not been identified. This patients multiple neurological and general pediatric problems should be assessed and treated by a pediatric neurologist. A child who has required three anticonvulsant medications for seizure control is considered refractory.  A refractory patient requires care by a neurologist skilled in epilepsy control.  Treatment by a pediatric neurologist is standard of care in this clinical scenario.  In this patients case, continued neurological follow-up visits with a pediatric neurologist is medically indicated.
Appeal type: Medical Necessity
Decision: Overturned

Findings:  The physician reviewer found that the patient has history of hepatitis C and arthritis. Her physician ordered Mavyret for 8 weeks. The Health Plan denied the request as not medically necessary. At issue is in this case is whether the medication Mavyret 100/40 mg for eight weeks is medically necessary for the treatment of the patient's medical condition.Per recent medical literature, Mavyret is indicated in patients with hepatitis C, genotype 1, for both new treatment and for experienced patients. Mavyret has been shown to result in 99 percent sustained viral response rate for the 8 and 12 week regimens. According to the Food and Drug Administration (FDA), Mavyret is the first product with a recommended eight week course of therapy for chronic hepatitis C viral infection. This for infection caused by viral genotypes 1-6 in treatment-naive adults without cirrhosis. In this case, the documentation supports the diagnosis of hepatitis C in this patient. The patient has not been treated for hepatitis C. The patient meets the FDA indications for treatment with Mavyret. Therefore, the requested medication Mavyret 100/40 mg for eight weeks is medically necessary.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 infectious disease 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested Botox injections for the treatment of her migraines.Findings:  Three physician reviewers found that Botox has been demonstrated to be beneficial for chronic migraine which can be defined as headaches greater than 14 days per month, at least eight of which are migraine or linked to migraine.  In this patients case, the records do not confirm this diagnosis.  The provided records do not document any information about the patient clinically, such as baseline headache frequency, number of prior Botox injections, or any evidence that there has been a benefit with Botox.  All told, Botox injections were not and are not likely to have been superior over other treatment options.  Final Result: Three reviewers determined that the services at issue were not, and are not likely to be more beneficial for treatment 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 neurology, 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

A 43-year-old male enrollee requested authorization and coverage of continued rehabilitation therapy for the treatment of ruptured cerebral aneurysm.  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 services are 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 authorization and coverage for Zepatier for 12 weeks for treatment of the enrollee's hepatitis C.Findings: The physician reviewer found 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. This recommendation applies to all patients, regardless of fibrosis stage. The guidelines recommend that treatment-naive, genotype 1b patients should be treated with regimens including Zepatier for 12 weeks, based on clinical trial results showing a 99% cure rate regardless of nonstructural protein 5A (NS5A) resistance. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, Zepatier for 12 weeks is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested medication regimen 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 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: Overturned

A 49-year-old male enrollee has requested Lexapro 10mg for the treatment of his generalized anxiety disorder. Findings:  The physician reviewer found that there is data to support the use of an antidepressant that has benefitted a family member. An article by Lin and Chen indicates that based on theories of pharmacogenomics, since the patients immediate family member did well on Lexapro, it may well benefit him. The authors state that, Evidence is accumulating to suggest that the efficacy of antidepressants results from the combined effects of a number of genetic variants. Additionally, while antidepressants are equally efficacious in theory, they are not equivalent in terms of side effect profiles. Paroxetine (Paxil) tends to cause more weight gain, sexual side effects and interdose withdrawal symptoms. Withdrawal symptoms are also seen with missed doses of venlafaxine (Effexor), which can also elevate blood pressure. In terms of its side effect profile and possible drug interactions, Lexapro is a cleaner drug than Paxil or Effexor. In sum, as this patient has already exhibited side effects to Luvox, it is medically reasonable and appropriate to treat him with Lexapro.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting authorization and coverage for circumcision. On a visit with the urologist, the enrollee indicated he wanted a circumcision due to irritation from pubic hair.  He denied issues with urinating or sexual intercourse and stated he desired to keep his pubic hair instead of shaving. On examination, the urologist documented easily retractable foreskin and normal genitalia. He did not recommend circumcision; however, the enrollee wanted the surgery.  Complications were discussed with the enrollee and the procedure was scheduled. Per the medical literature, some commonly accepted indications for circumcision include failure of medical management for recurrent balanoposthitis (inflammation of the glans and foreskin); non-retractable foreskin at the age of sexual activity; lichen sclerosis et atrophicus, BXO; neoplasm of prepuce; traumatic injury to foreskin, voiding obstruction, pam phimosis and phimosis. There is insufficient evidence in the record of these or any other conditions that would necessitate a circumcision in this enrollee.Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in urology 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A forty-eight year-old female with excessive daytime sleepiness is requesting reimbursement for twice per day Provigil and prospective authorization and coverage for three times per day Provigil.  Reviewers Findings:  The reviewing physician found that the patient should be reimbursed for her out of pocket expense for the purchase of Provigil.  There is no support in the record for an increase in the dosage to three times per day.  The reviewing physician found that the Health Plan denial should be partially overturned.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: According to recent American Diabetes Association (ADA) guidelines, most patients using intensive insulin regimens (multiple-dose insulin or insulin pump therapy) should perform [self-monitoring blood glucose] SMBG prior to meals and snacks, at bedtime, occasionally postprandially, prior to exercise, when they suspect low blood glucose, after treating low blood glucose until they are normoglycemic, and prior to critical tasks such as driving. For many patients, this will require testing 6-10 (or more) times daily, although individual needs may vary. The notes provided for review indicate that this patient is on an insulin pump that requires use of the Freestyle Lite test strips. This is true for the Omnipod insulin pump system. Freestyle meters require the smallest blood sample size. So for a young patient that is self-monitoring 10 times a day, this is very important. In the latest review of glucose meters, the Freestyle sample size is 0.3 microliters versus AccuCheck which is 0.6 microliters. Given these findings, the requested Freestyle Lite test strips (300 strips per month) are medically necessary for evaluation of this patients type 1 diabetes. Final Result: The reviewer determined that the requested supplies are 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 internal medicine with sub-specialty certification in endocrinology, diabetes 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: Medical Necessity
Decision: Upheld

A 50-year-old male enrollee has requested for a spinal cord stimulator for treatment of his chronic low back pain. Findings:  The physician reviewer found that the lack of documented evidence that the trial was successful, the medical necessity for proceeding with implantation of a spinal cord stimulator system has not been established. If objective documentation from the patients physician is provided which demonstrates that the patient had a good response to the stimulation trial, the patients request should be reconsidered.
Appeal type: Medical Necessity
Decision: Overturned

A 48-year-old male enrollee has requested inpatient treatment for his alcohol dependence. Findings:  The physician reviewer found that per the American Psychiatric Association guidelines for treatment of substance abuse, there are several criteria that correlated with placing this patient in an inpatient level of care. According to these guidelines, inpatient level of care is needed when an individual has a documented history of not engaging in or benefiting from treatment in a less intensive setting and when the patient manifests substance use or other behaviors that make him an acute danger to himself or others. This patient had not responded to less intensive treatment efforts. Thus, this patient met American Psychiatric Association (APA) guidelines for inpatient care.