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

The parent of a 15-year-old female enrollee has requested continued residential treatment for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found that the submitted documentation establishes the medical necessity for the services at issue. Treatment at the residential level of care was indicated initially for this patient who was demonstrating pathologic behaviorism, emotional dysregulation, interpersonal strife, anxiety, agitation and mood symptoms. The residential placement has been a successful intervention. In fact, the most recent notes in the medical record suggest that the patient has consolidated therapeutic gains to the point where transition to a less restrictive setting would be appropriate. Recent documentation notes the absence of anger, insomnia, mood swings or self-harm urges, and improving insight. The patient has undergone significant medication changes and is tolerating the new regimen. Additionally, the patient had a positive family therapy session that focused on family values and expectations. The patient has been active and making progress in her other therapies as well.  Given the patients therapeutic progress, it would be medically appropriate to begin the transition process to a less intensive level of care. Considering the degree of dysfunction and pathology that prompted the patients admission, a well-planned and smooth transition to a lower level of care is required. Based on the documentation provided, the disputed services have been medically necessary but the patient is now appropriate for transition to a less restrictive setting. To minimize morbidity, and facilitate adequate follow-on services and both patient and family preparation, continuation of residential treatment services until the date indicated is medically reasonable and necessary.
Appeal type: Medical Necessity
Decision: Overturned

A 37-year-old female enrollee requested authorization and coverage of gastric bypass surgery. The Health Plan denied the request indicating that the requested procedure is not medically necessary for treatment of the enrollees morbid obesity.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.
Appeal type: Medical Necessity
Decision: Overturned

An enrollee has requested authorization and coverage for weekly outpatient psychotherapy services.  The Health Plan has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees behavioral health condition.Findings:  There is support in the medical literature for the requested services in this clinical setting. There is no defined frequency or duration for the amount of psychotherapy required for each patient; however, it is generally accepted that patients in crisis require more frequent sessions than patients who are stable. The medical literature also supports that in unrestricted therapies, each additional psychotherapy session has a diminished effect. An article by colleagues reports: our findings suggest that, at least in unrestricted therapies, the average rate of change during psychotherapy can be expected to diminish with each additional session irrespective of the length of treatment. These results are consistent with previous studies. Given this information, the patients symptoms impair the patients functionality. According to the medical literature and standard practice, this patient requires a period of intense, frequent psychotherapy sessions to help improve her symptoms. Intense treatment psychotherapy protocol is usually 12 to 14 sessions. The patient could then reduce the frequency of her psychotherapy sessions to bimonthly and then to monthly depending on the patients progress. Accordingly, a portion of the requested outpatient psychotherapy services has been demonstrated as medically necessary for treatment of this patients medical condition. Specifically, this patient would benefit from weekly psychotherapy sessions for up to sessions. The patient should then be re-evaluated to determine the frequency of psychotherapy sessions going forward.Final Result: The reviewer has determined that a portion of the requested services is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially 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: Overturned

The parent of an 8-year-old male enrollee requested social skills services in a group setting for medical treatment of the enrollees autism spectrum disorder.  Findings:  The physician reviewer found that the submitted documentation and relevant literature demonstrates the medical necessity of social skills services.  It is important that patients in this clinical setting be introduced to socializing and interacting with their peers. According to Myers and colleagues, families can facilitate joint attention and other reciprocal social interaction experiences throughout the day in the childs regular activitiesa social skills curriculum should target responding to the social overtures of other children and adults, initiating social behavior, minimizing stereotyped perseverative behavior while using a flexible and varied repertoire of responses, and self-managing new and established skills. This patients experiences through his group social skills therapy have been successful and are well-documented by his teachers, his in-Plan autism case manager and his parent. Therefore, it is medically necessary that the patient receive social skills services in a group setting. Based on the medical literature cited above and the documentation submitted for review, the requested services are medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 71-year-old male enrollee requested authorization and coverage of the medication Proscar. The Health Plan denied the request indicating that the requested medication is not medically necessary for the treatment of the enrollees hematuria.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested medication is not medically necessary.
Appeal type: Experimental/Investigational
Decision: Overturned

A female enrollee requested wireless capsule endoscopy of the gastrointestinal tract for medical evaluation of her medical condition.  Findings:  Two physician reviewers found that the American Gastroenterological Association guidelines recommend video capsule endoscopy to investigate patients with occult blood in stool and negative esophagogastroduodenoscopy and colonoscopy, such as in this patients case.  In appropriately selected patients, the technology has a high yield and can avoid more invasive procedures. Therefore, the requested wireless capsule endoscopy of the gastrointestinal tract is likely to be more effective than other methods of evaluating this patient.
Appeal type: Medical Necessity
Decision: Upheld

A 28-year-old female enrollee has requested Focalin IR 40mg three times a day and Focalin XR 20mg to 40mg daily for treatment of her behavioral health condition.   Findings:  The physician reviewer found that Focalin IR 40mg three times a day and Focalin XR 20mg to 40mg daily are not medically necessary for this patients medical condition. According to the U.S. Food and Drug Administrations (FDA) and the manufacturers prescribing information, the combination of both Focalin IR and XR is not recommended. Anecdotal evidence of augmentation or booster dosing exists, however, FDA and manufacturers guidelines do not indicate the use of both preparations simultaneously. In a letter by the patient she identifies the necessity for the requested doses of Focalin as relating to her higher tolerance for medication due to opiate use, lack of efficacy of other tried agents and continued use of lithium as having a negative impact on normal dosing. The FDA and manufacturers prescribing information shows no evidence of opiate induced tolerance and/or diminished efficacy with comorbid lithium administration. Furthermore, the combined dosage of both preparations exceeds FDA guidelines and is not consistent with generally accepted standards of practice. While the patient cites the combination and dosage to be effective, there are safety concerns associated with this combination given the increased potential for cardiac symptoms, mood dysregulation and potential for abuse. For the reasons provided above, the requested medications are not medically necessary for treatment of the patients medical conditions.
Appeal type: Experimental/Investigational
Decision: Overturned

A 44-year-old male enrollee has requested an electrical bone growth stimulator for treatment of his tibia fracture.  Findings:  Three physician reviewers found that the requested bone growth stimulator is likely to be more efficacious than other treatment options in this patients case.  This patient has pain at the fracture site and radiographic evidence of a 4 mm fracture gap.  There is adequate support for the requested equipment in this clinical setting.  The current literature supports a positive effect of bone growth stimulators for accelerated healing of fractures of the tibia.  Thus, use of an electrical bone growth stimulator is likely to be of greater benefit than other alternatives for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

A 48-year-old female enrollee has requested radiofrequency neuroablation for the treatment of her thoracic spinal stenosis. Findings:  Two physician reviewers found that thoracic facet joints have been implicated as the source of chronic pain in the mid back or upper back in 34% to 48% of patients. Various therapeutic techniques utilized in managing chronic thoracic pain of facet joint origin include intra-articular injections, medial branch blocks, and radiofrequency neuroablation of the thoracic facet joint nerves. At this time, there is a lack of outcome data from large, long-term, well-designed studies  demonstrating that radiofrequency neuroablation of the thoracic facet joint nerves confers a superior benefit over standard therapeutic modalities available in this setting. Thus, there is no compelling evidence which clearly establishes that the disputed procedure has greater efficacy in the treatment of chronic back pain.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Oncotype Dx prostate cancer testing. Findings:  Three physician reviewers found that the Oncotype DX testing provided was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Gene expression analysis utilized to guide management of prostate cancer remains controversial. There is a lack of evidence from well conducted prospective clinical trials demonstrating that the utilization of Oncotype Dx has an impact on patient health outcome. Thus, the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: 2 of 3 reviewers determined that the testing at issue was 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 physician reviewers are board certified in urology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 53-year-old male with the diagnosis of localized prostate cancer staged as T1C with Gleason grades 6 and 7. The patient presented with an elevated PSA indicating the need for a biopsy. The prostate cancer was non-palpable but was identified in both lobes on biopsy. The patient consulted with a non-Plan specialist regarding treatment options, and is now requesting authorization for proton beam radiation therapy at a non-Plan medical center. The Health Plan denied the patients request based upon a determination that this therapy is not medically necessary.The definitive treatments for prostate cancer are either surgery or radiation therapy. Surgery is defined as radical prostatectomy, and radiation therapy can be delivered as either external beam or in the form of brachytherapy. The current standard of care for radiation therapy is intensity modulated radiation therapy (IMRT). Proton beam therapy is another form of radiation therapy using protons instead of photons. The literature shows no significant advantages in terms of cure or side effects when these two modalities are compared. In fact, some centers mix both conventional and proton therapy in one treatment plan since time on the machine is by necessity limited. When proton therapy was compared with the older 3D conformal radiation it did have fewer side effects, however the patient has been offered IMRT so this is not a relevant consideration. The patient can expect excellent results with low morbidity with IMRT. Therefore, I have determined 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

Nature of Statutory Criteria/Case Summary: The patient is requesting approval of brand-name Vivelle-Dot Patch to control her symptoms. The Health Plan has denied the requested brand name formulary exception.Hormone replacement therapy is an effective treatment for menopausal symptoms such as vasomotor symptoms. According to multiple professional groups, including the Endocrine Society and American College of Obstetricians and Gynecologists (ACOG), all forms of systemic estrogen replacement therapy have been found to be equally effective for the treatment of menopausal symptoms. The patients formulary contains multiple systemic estrogens. The patient's specific indication for this treatment is not clear in the clinical documentation. The patient states in a letter that she has used generic versions in the past, but there is no supporting clinical documentation by her provider. There is no clinical documentation to support that she has tried and failed any alternative hormone replacement medications, or that that they cause adverse effects. There is also a lack of evidence in the peer-reviewed medical literature that Vivelle-Dot Patch would be more effective than the available formulary medications. Therefore, the requested brand name formulary exception for Vivelle-Dot Patch is 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 obstetrics and gynecology 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a behavior therapist at the frequency of eight hours per week, board certified behavior analyst (BCBA) supervision at the frequency of six hours per month, parent training at the frequency of six hours per month and assessment and treatment planning at the frequency of three hours per month for treatment of the autism. Findings: The physician reviewer found that the requested services are medically necessary for treatment of the patients medical condition. Adolescents with autism spectrum disorders have a high rate of irritability and aggressive symptoms (Robb). Matson and colleagues note that because of adults increased physical size and longer history of these problems, treating these behaviors effectively is important. Psychological methods, particularly ABA therapy, and pharmacotherapy have been the most frequently addressed treatments for challenging behaviors associated with autism spectrum disorder. The medical literature demonstrates that severe problem behaviors such as aggression, self-injury, and property destruction can result in injury, and that behavioral interventions can significantly reduce such behaviors. In this case, the patient is displaying aggressive behavior and property destruction that could result in injury to himself or others. As such, the request for behavior therapist at the frequency of eight hours per week, BCBA supervision at the frequency of six hours per month, parent training at the frequency of six hours per month and assessment and treatment planning at the frequency of three hours per month are medically necessary for treatment of the patients autism. 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 pediatrics with sub-specialty certification in developmental-behavioral pediatrics 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 parents of a 17-year-old female enrollee requested authorization and coverage of residential care for the treatment of an eating disorder .  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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested reimbursement for Optune device (CPT E0766 - electrical stimulation device used for cancer treatment, includes all accessories, any type) provided on 4/01/21 through 5/01/21.Findings: Three out of three physician reviewers found that Optune device provided on 4/01/21 through 5/01/21 was likely to have been more beneficial for the enrollee than any available standard therapy.Anaplastic astrocytomas and glioblastoma multiforme are high grade tumors that are best treated with resection, radiation therapy, and chemotherapy. Chemotherapy prolongs survival, but the gains are modest. The standard of care is to resect the glioblastoma maximally followed by treatment with temozolomide. Most glioblastoma tumors recur, and then the treatment options are limited. In 2011, the U.S. Food and Drug Administration approved Optune, formerly known as the NovoTTF-100A device, to deliver alternating electrical fields to treat recurrent glioblastoma. Stupp and colleagues conducted a study comparing NovoTTF to the best standard of care chemotherapy. The authors found, No improvement in overall survival was demonstrated, however efficacy and activity with this chemotherapy-free treatment device appears comparable to chemotherapy regimens that are commonly used for recurrent glioblastoma. Toxicity and quality of life clearly favored NovoTTF. In this case, the patient has exhausted standard treatment. Therefore, Optune device (CPT E0766 - electrical stimulation device used for cancer treatment, includes all accessories, any type) provided on 4/01/21 through 5/01/21 was likely to have been more beneficial for the patient than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Xifaxan. The American College of Gastroenterology (ACG) guidelines recommend Xifaxan for the treatment of IBS-D based on safety and high efficacy in clinical studies. In addition, the U.S. Food and Drug Administration (FDA) has approved Xifaxan for the treatment of IBS-D. Clinical studies have reported positive health outcomes with Xifaxan for patients with IBS-D. The documentation supports that this patient has IBS-D. Treatment with alternative therapies has been unsuccessful. The quantity and duration requested is appropriate and consistent with the FDA approval. For these reasons, the requested Xifaxan 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. Credentials/Qualifications: The reviewer is board certified in internal medicine with subspecialty 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.