Persius/imr-appeals huggingface dataset:
The patient is a 42-year-old female with previously diagnosed depression, morbid obesity, and binge eating disorder, though not bulimia per se. The patient was admitted to partial hospitalization on 2/16/04 where she was treated with a number of psychotherapies as well as Lexapro. Pertinent social stressors have included her mothers alcohol dependence, an emotionally abusive husbands past infidelity, and her teenage sons involvement with drugs and alcohol and poor performance in school. Her tendency has been to overeat when distressed. During her stay in the partial hospitalization program, the patients weight decreased from 334 pounds to 319 pounds by 5/12/04. The chart notes point to the patients growing insight about her aforementioned stressors and her emotional reaction by way of overeating. The therapists notes of 5/5/04 indicate, her family is emotionally reacting to her positive changes. In discussing this the patient made many realizations and showed great insight. The patient has requested authorization and coverage for continued partial hospitalization services. The Health Plan has denied the request indicating that the submitted documentation does not demonstrate partial hospitalization services were medically necessary as of 5/12/04.Analysis and Findings:While the patient entered partial hospitalization to better contain her overeating and anxiety, she had a rather protracted course of such treatment for a multitude of problems that are often treated with no more intensive therapy than outpatient care. In any event, the submitted records indicate the patient improved during partial hospitalization, experiencing a weight loss of approximately 15 pounds, and a growing awareness of the triggers for overeating. There is nothing in the submitted records to indicate the patient warranted partial hospitalization beyond 5/12/04. There is no evidence that as of 5/12/04 the patient was experiencing any particularly acute problems. Outpatient treatment services as recommended by the Health Plan are medically reasonable and appropriate for the ongoing care of this patient. Based upon the information set forth above, I have determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.
The patient is a 43-year-old female who presents with neck and back pain as well as right side upper extremity pain. No cause or incident for the pain is evident. Chiropractic care has been provided 18 times over several months. The patient indicates she is in constant pain and is unable to work despite a recent course of chiropractic care. The patient notes on the chiropractic intake forms that her complaints are all the time, extreme, and she has neck pain on swallowing. An x-ray exam has been requested by the chiropractor but the submitted documentation does not indicate if the exam was performed. The patient has requested authorization for continued chiropractic care. The Health Plan has denied the patients request on the basis that continued chiropractic care is not medically necessary for treatment of the patients medical condition.Upon review of the patients records it appears she has made little progress with chiropractic care. Additionally, the submitted records do not demonstrate that other causes for the patients arm complaints have been ruled out or that referrals have been made. Chiropractic care has been given an adequate opportunity to cure or relieve the patients pain. Continued chiropractic care is not likely to be clinically beneficial to this patients current complaints. The patient should receive a referral to her primary care physician for further workup or a referral to rule out other causation or to suggest possible curative care approaches. Based upon the information set forth above, I have determined that the requested therapy is not medically necessary for the treatment of the patients medical condition. The Health Plans denial should be upheld.
The patient is a five-year-old male who has been diagnosed as having ADHD, hyperactive type. Pervasive developmental disorder - not otherwise specified, and mental retardation have been ruled out. The patient was initially treated with Adderall immediate release with positive response. The medication was later switched to Adderall XR (long-acting), which was given only once per day. The patient continues to have positive response to Adderall therapy. The patient has not been tried on any other psychostimulant. A request has been made for authorization of Adderall XR. The Health Plan has denied the request on the basis that Adderall XR is not medically necessary. Though the submitted records indicate the patient has had a positive response to Adderall XR it has not been established that Adderall XR is medically necessary for treatment of the patients ADHD. The records demonstrate the patient had significant positive response to immediate release Adderall. There is no documentation of significant rebound on the immediate release version of Adderall. Furthermore, Adderall XR has not been approved for use in children under the age of six. Moreover, the submitted documentation does not demonstrate the patient has experienced complications that would warrant use of the long-acting version of Adderall. Based upon the information set forth above, I have determined that the requested medication is not medically necessary for the treatment of the patients medical condition. The Health Plans denial should be upheld.
A 28-year-old female enrollee requested authorization and coverage of biofeedback therapy. The Health Plan denied the request indicating that the requested therapy is considered investigational for treatment of the enrollees rectal incontinence. Three physician reviewers performed an experimental/investigational Independent Medical Review. Two of the three physician reviewers concluded that the requested therapy is likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy. One of the three physician reviewers concluded that the requested therapy is not likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy. Because two of the three physician reviewers concluded that the requested therapy is likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy, the Health Plans denial has been overturned.
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.
A 57-year-old female enrollee requested authorization and coverage of an MRI of the left breast. The Health Plan denied the request indicating that the requested MRI is not medically necessary for evaluation of a lump in the enrollees breast.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plans denial on the basis that the requested MRI is medically necessary.
A 38-year-old female enrollee requested authorization and coverage of gastric banding. The Health Plan denied the request indicating that the requested procedure is considered investigational for treatment of the enrollees morbid obesity.Three physician reviewers performed an experimental/investigational Independent Medical Review. Two of the three physician reviewers concluded that the requested procedure is likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy. One physician reviewer concluded that the requested procedure is not likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy. Because two of the three physician reviewers concluded that the requested procedure is likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy, the Health Plans denial has been overturned.
A 43-year-old female enrollee requested authorization and coverage of a gastric bypass surgery consultation. The Health Plan denied this request indicating that the requested consultation is not medically necessary for evaluation 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 consultation is medically necessary.
A female enrollee requested authorization and coverage of Botox injections. The Health Plan denied the request indicating that the requested therapy is considered experimental for treatment of the enrollees hyperhidrosis.Three physician reviewers performed an experimental/investigational Independent Medical Review. All three physician reviewers concluded that the requested therapy is likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy. Because all three physician reviewers concluded that the requested therapy is likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy, the Health Plans denial has been overturned.
A 30-year-old male enrollee requested authorization and coverage of a bilateral mastectomy with ultrasound and suction-assisted lipectomy. The Health Plan denied the request indicating that the procedure is cosmetic in nature and not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested procedure is cosmetic in nature and not medically necessary.
A 43-year-old male enrollee requested authorization and coverage of a nebulizer. The Health Plan denied the request indicating that the requested equipment is not medically necessary for treatment of the enrollees asthma.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.
A 35-year-old female enrollee requested authorization and coverage for 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.
Summary Reviewer 3 
A 31-year-old female has requested reimbursement for lab tests that measure the levels of 
medication, adalimumab (ADA) performed on 8/1/22. The Health Insurer has denied this request 
indicating that the testing at issue was considered investigational for evaluation of the insureds 
ulcerative colitis. The physician reviewer found that on review of the current peer-reviewed 
medical literature, the drug assay testing for ADA performed on 8/1/22 was likely to be more 
beneficial for the evaluation of this patient than any available standard therapy. The drug testing 
performed was reactive drug monitoring since the test was recommended in response to the 
patients symptoms of ulcerative colitis. The most recent national guideline from the AGA 
specifically  endorses  reactive  drug  monitoring  in  this  clinical  setting  when  the  patient  has 
symptoms while on anti-TNF agents such as ADA (Feuerstein, et al.). The AGA guidelines cite 
data that has shown that reactive drug monitoring is more beneficial than standard therapy 
including  change of  drug therapy without the drug  assay  and  is  supported with  consensus 
agreement among experts (Feuerstein, et al.; Papamichael, et al.). Thus, the lab tests that measure 
the levels of adalimumab performed on 8/1/22 was likely more beneficial for evaluation of the 
patient than any available standard therapy.
Summary Reviewer 1

A 63-year-old female enrollee has requested reimbursement for ExoSym kinetic orthosis for right knee provided on 9/12/16. The Health Insurer has denied this request indicating that the device at issue was considered investigational for treatment of the enrollees right knee pain. The physician reviewer found that the ExoSym kinetic orthosis is a customizable energy-storing device that is designed to support and protect an array of lower extremity limb injuries. However, at this time, there is a lack of evidence to support that the published results can be duplicated on a reliable basis. Until quality data becomes available, this orthosis does not have adequate support for use outside of a clinical trial. Accordingly, the ExoSym kinetic orthosis for right knee provided on 9/12/16 was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Based upon the information set forth above, the device at issue was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Summary Reviewer 


A 47-year-old female enrollee has requested reimbursement for the chiropractic care services provided from 1/27/16 through 7/6/16. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees neck and shoulder pain. The physician reviewer found that the American College of Occupational and Environmental Medicine (ACOEM) state that if manipulation does not bring improvement in three to four weeks, it should be stopped and the patient reevaluated. In this case, while the patient presented with subjective pain, the provider has not documented clinical assessments and evaluations to support continued treatments. Most importantly, the records do not include discussions on objective functional improvement as an indication for the extended duration of care. Per 10/19/15 report, the patient was instructed to use ice as needed and to take NSAIDs at her discretion. The patients diagnosis on 7/6/16 included cervicalgia and pain in right shoulder. Overall, the medical necessity for continued chiropractic care cannot be determined without documentation of objective functional improvement. Therefore, reimbursement for the chiropractic care services provided from 1/27/16 through 7/6/16 were not medically necessary for treatment of this patients medical condition. Based on the records provided, the services at issue were not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.
Summary Reviewer 2 
 
A 27-year-old female enrollee has requested authorization and coverage for E1399 durable 
medical equipment RT300 FES arm therapy system. The Health Insurer has denied this request 
and reported that the requested device is investigational for the treatment of the enrollees 
medical condition. The physician reviewer found that the E1399 RT300 FES arm therapy system 
is not likely to be more beneficial than other available standard therapy. It is uncertain whether 
FES  can  restore  upper-extremity  function  or  improve  the  quality  of  life.  The  evidence  is 
insufficient to determine the effects of the technology on health outcomes. The evidence for the 
effectiveness of the RT300 FES cycling in people with stroke is limited. There is insufficient 
evidence in the literature that supports that the use of the RT300 FES will be effective for this 
patients hemiplegia from stroke in long-term improvement of muscle strength, vascular blood 
flow, bone mineral density, reduction of spasticity and atrophy, facilitation of functional motor 
movement  or  reduction  muscle  atrophy  in  the  upper  and  lower  extremities.  Eraifej  and 
colleagues performed a meta-analysis of 20 studies on the benefits of FES on activities of daily 
living. Only three studies showed a significant benefit of FES on activities of daily living when 
initiated within two months post-stroke. In three studies where FES was initiated more than one 
year after stroke, no significant activities of daily living improvements were seen. Limitations of 
the evaluable studies included, very low quality evidence in all analyses due to heterogeneity,  low participant numbers and lack of blinding. The authors concluded that FES is a promising 
therapy that could play a part in future stroke rehabilitation. They noted that there is a need for 
high quality large-scale randomized controlled trials of upper limb FES after stroke to draw firm 
conclusions regarding its efficacy or its optimum therapeutic window. The evidence that FES 
cycling can have a long-term effect on bone mineral density is not found in the literature. An 
additional study done on the prevention and treatment of osteoporosis by Soleyman-Jahi and 
colleagues revealed very low-quality evidence that low-intensity cycling (three days per week) 
with FES provided a benefit for reducing bone mineral density loss in individuals with chronic 
spinal  cord  injury  or  neurologic  injury.  All  told,  the  current  medical  evidence  has  not 
demonstrated the superior efficacy of the requested device. Therefore, the requested for E1399 
durable medical equipment RT300 FES arm therapy system is not likely to be more beneficial 
than any available standard therapy.
Summary Reviewer 1


A 42-year-old female enrollee has requested reimbursement for the digital breast tomosynthesis provided on 10/7/16. The Health Insurer has denied this request indicating that the services at issue are considered investigational for evaluation of the enrollees breast cancer examination.  The physician reviewer found that the American College of Radiology urged tomosynthesis be removed from the investigational category in 2014 due to the advantage it brings radiologists interpreting mammograms especially in patients with dense breasts such as the patient under review. This tomographic method often allows the reader to separate dense glandular elements from underlying mass/architectural disorder resulting in a decrease in callbacks and increase in detection of small cancers compared to two-dimensional (2D) imaging alone. In this case, the use of tomosynthesis likely aided the radiologist to detect the area of interest in the left breast in this patient with dense breast tissue. Thus, the addition of tomosynthesis was likely of greater benefit to the patient than had her exam been done with 2D imaging alone. For this reason, the digital breast tomosynthesis performed on 10/7/16 was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Based upon the information set forth above, the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Summary Reviewer 


A 58-year-old female enrollee has requested authorization and coverage for Harvoni. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees chronic hepatitis C virus genotype 1b.  The physician reviewer found that 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 virus, regardless of fibrosis, should be treated except those with a life expectancy of less than 12 months due to non-liver-related comorbid conditions. In addition, treatment naive patients are recommended to be treated with Harvoni for 12 weeks. These recommendations are based on multiple randomized clinical trials, and the medication is U.S. Food and Drug Administration (FDA) approved for all patients with chronic hepatitis C genotype 1 regardless of fibrosis stage. Moreover, it is beneficial to treat patients with hepatitis C before they progress to F3 or F4 fibrosis. For these reasons, the requested treatment with Harvoni is supported as medically necessary for treatment of this patients hepatitis C virus infection. Based on the foregoing discussion, the requested medication is medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Summary Reviewer 3

A 57-year-old female enrollee has requested reimbursement for testing for cancer risk using panels of genes (MyRisk) provided on 6/05/19. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrollees medical condition. The physician reviewer found that this patients family history is suggestive of a breast/ovarian cancer syndrome. BRCA1 mutation can increase risk for breast, ovarian, cervical, uterine, pancreatic, gastric, and prostate cancers. BRCA2 mutations can increase risk for breast, ovarian, gallbladder, bile duct, prostate, pancreatic, and gastric cancers. In the event the BRCA tests were negative, there is still a possibility of hereditary predisposition from another gene defect. There are guidelines in place that evaluate the occurrence of Lynch syndrome or hereditary nonpolyposis colorectal cancer tumors in families. The most common extracolonic cancer in Lynch syndrome is endometrial cancer followed, in no particular order, by ovarian, gastric, renal, small intestine, pancreas, hepatobiliary, and ureteral. The MyRisk panel is appropriate since the current clinical situation may be caused by several potential cancer-causing genes. Thus, testing for cancer risk using panels of genes (MyRisk) provided on 6/05/19 was likely to have been more beneficial than other methods of evaluating this patient.
Summary Reviewer 


A 52-year-old female enrollee has requested reimbursement for computed tomography (CT) scan of the sinuses performed on 1/12/16.  The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees medical condition. The physician reviewer found the submitted documentation fails to demonstrate the medical necessity of the services at issue.  The medical literature supports the use of CT scan in diagnosis and treatment planning in the setting of chronic recurrent rhinosinusitis.  However, it is not within standard of care to repeat a scan in this clinical setting.  There is no medical indication for this patient to have undergone a second CT one month after a prior scan showed lack of disease.  All told, the CT scan of the sinuses performed on 1/12/16 was not medically indicated in this particular situation.  Therefore, the services at issue were not medically necessary for evaluation of the patients medical condition. The Health Insurers denial should be upheld.