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

The patient is a 47-year-old female who has requested authorization and coverage for Crinone 8% gel. The patient states that she has irregular menses, is perimenopausal, is depressed, has mood swings, and has a hormonal imbalance. The submitted notes indicated the patient was given a refill of Lo-Orval (oral contraceptives) and a testosterone gel. There is also a report of her having normal hormonal levels, which indicate that she is not menopausal. There is some indication that the irregular menses might be due to breakthrough bleeding from the oral contraceptives. The Health Plan has denied the patients request for Crinone gel on the basis that it is not medically necessary for treatment of her menopausal symptoms.Crinone gel is not medically necessary. Crinone gel is progesterone and there is no indication for its use in this patient. Progesterone is commonly used in patients of this age to control abnormal bleeding but not depression and mood swings. If progesterone were needed, oral progesterone would be preferable. Birth control pills are the equivalent, and indeed, provide a higher dose of hormonal replacement therapy. To the extent that any of the patients symptoms were due to menopausal or hormonal factors, her use of birth control pills should have helped to alleviate her symptoms. An evaluation should be performed to determine if there is any abnormal bleeding. If so, further diagnostic testing should be performed.  Based upon the information set forth above, I have determined that the requested gel 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 58-year-old male enrollee requested authorization and coverage of an MRI of the brain. The Health Plan  denied the request indicating that the requested MRI is not medically necessary to rule out stroke.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested MRI is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

The spouse of a 61-year-old male enrollee has requested for inpatient rehabilitation services for treatment of the enrollees traumatic brain injury. Findings:  The physician reviewer found that it is unlikely that an inpatient program aimed at traumatic brain injury compensatory strategies would significantly alter the patients functional status.
Appeal type: Medical Necessity
Decision: Overturned

A male enrollee requested proton beam therapy for medical treatment of his acoustic neuroma.  Findings:  The physician reviewer found that although this patient does not have useful hearing in his left ear, failure to treat this intracranial tumor could result in its growth and subsequent development of balance difficulty, facial nerve pain, numbness, dysphagia and vertigo. Given the current medical literature, proton beam therapy has an advantage over other forms of radiation in the management of acoustic neuroma (Combs, et al; Link, et al). This includes central nervous system lesions measuring less than 3 cm in diameter adjacent to critical structures such as optic nerve, base of skull, brain stem or spinal cord. The critical structure in relation to a CP angle tumor is the brainstem. Based on these findings, the requested proton beam radiation therapy is medically necessary for treatment of this patients acoustic neuroma.
Appeal type: Experimental/Investigational
Decision: Upheld

A 53-year-old female enrollee has requested  for hyperthermia therapy (in combination with radiation therapy) for treatment of her lung cancer. Findings:  Three physician reviewers found that a review of the literature shows that one relevant randomized trial has been performed. As reported by Mitsumori, et al, 80 patients with locally advanced non-small cell lung cancer were randomized to radiation (RT) or radiation plus hyperthermia (RHT). Although there was a statistically significant improvement in local progression-free survival favoring RHT, the study showed no differences in either the local response rate or the overall survival.
Appeal type: Experimental/Investigational
Decision: Overturned

A 29-year-old male enrollee has requested CT-guided radiofrequency ablation (RFA) for the treatment of his metastatic synovial cell sarcoma. Findings:  Two physician reviewers found that pulmonary RFA has become the standard of care for patients with inoperable metastatic disease including colorectal, breast, and pulmonary primary disease in many institutions throughout the United States. Pulmonary metastatic disease from synovial sarcoma is a rare malignancy and therefore does not have a large number of disease specific outcome data to support its use for or against treatment. It is evident that this patient has limited treatment options; chemotherapy and surgical resections have failed. However, RFA has been successful. This patient is a young active man. Surgical resection and further lung tissue removal could severely impact pulmonary function. RFA is a minimally invasive technique which will offer the patient a better chance of cure for these new, small lesions. The recovery period from RFA is also dramatically shorter and would potentially protect the patient from the clinical consequences of becoming pulmonary compromised. RFA offers a superior course of care in this setting.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for gallium-68 dotatate positron emission tomography (PET) scan. Findings: Gallium-68 dotatate PET is a functional imaging modality for the detection of well-differentiated neuroendocrine tumors. In addition, PET with dotatate injection has become the preferred method for initial diagnosis and localization for suspected unknown primary tumors. Studies have demonstrated that dotatate PET detects significantly more neuroendocrine tumors compared to octreotide imaging. According to the American College of Radiology (ACR) practice parameters, the performance of gallium-68 dotatate PET can be used to detect tumors in patients with strongly suggestive symptoms and laboratory evidence of neuroendocrine tumor but with no known primary tumor. This patient presented with an elevated urine 5-HIAA as well as a history of hypertension. In this patients clinical setting, evaluation with gallium-68 dotatate PET imaging was indicated to rule out neuroendocrine tumor. Therefore, the gallium-68 dotatate PET scan was medically necessary for evaluation of this patient. Final Result: The reviewer determined that the services at issue were 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 radiology 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

A 43-year-old female enrollee has requested lysis of epidural adhesions for the treatment of her cervical, thoracic and lumbar radiculopathy. Findings:  Two physician reviewers found that the practice guidelines previously cited support the use of percutaneous epidural adenolysis in this patient. These guidelines reviewed five randomized trials, two prospective evaluations and three retrospective evaluations for percutaneous lysis of lumbar epidural adhesions. The Health Plan policy incorrectly states the evidence is unchanged from 2005.
Appeal type: Medical Necessity
Decision: Overturned

A 36-year-old female enrollee has requested for removal of excess skin from the buttocks, hips, and arms for treatment of her excess skin. Findings:  The physician reviewer found that abdominoplasty is a procedure that involves placement of transverse suprapubic/lower abdominal and periumbilical incisions.  The abdominal skin is then tightened by excising the caudal portion of abdominal skin and creating a new umbilical opening higher up on the skin that has now been stretched downward.  Panniculectomy is a lesser procedure that only involves removal of the lower abdominal skin without the muscle tightening or the supraumbilical skin tightening via periumbilical and lower abdominal incisions.  A buttock lift is an abdominoplasty or panniculectomy that is extended circumferentially around the back of the body.  The submitted medical records do not support the existence of a skin condition in the buttock area or severe enough excess skin hampering function that would justify the medical necessity of a buttock lift.  Although the records support the existence of upper inner thigh skin rolls, they do not support the existence of a skin condition in this area or severe enough excess skin hampering function that would justify the medical necessity of a thigh lift. All told, the requested removal of excess skin from the buttocks and hips are not medically necessary and do not meet the criteria for reconstructive surgery.  The requested removal of excessive skin from the arms meets the criteria for reconstructive surgery.
Appeal type: Medical Necessity
Decision: Upheld

The patient has requested authorization and coverage for rhytidectomy and lip augmentation, along with the already authorized facial feminization surgery. The World Professional Association for Transgender Health (WPATH) acknowledges that, for certain patients, an intervention like a reduction rhinoplasty can have a radical and permanent effect on their quality of life, and therefore is much more medically necessary than for somebody without gender dysphoria. WPATH further states that although facial feminization procedures are labeled purely aesthetic, these procedures in an individual with severe gender dysphoria can be considered medically necessary, depending on the unique clinical situation of a patients condition and life situation. However, the records suggest that a rhytidectomy and lip augmentation would be performed to counter the effects of aging, not to address the patients gender dysphoria. All told, the requested rhytidectomy and lip augmentation, along with the already authorized facial feminization surgery, are not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in 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 58-year-old male enrollee has requested for decompression therapy or an epidural for treatment of his low back pain and neck pain. Findings:  The physician reviewer found that there is insufficient evidence regarding the efficacy of decompression. A literature review was performed by Macario and Pergolizzi to assess the efficacy of non-surgical spinal decompression achieved with motorized traction for chronic discogenic lumbosacral back pain. The authors concluded that the efficacy of spinal decompression for chronic discogenic low back pain remains unproven. They opined that more scientifically rigorous studies with better randomization, control groups, and standardized outcome measures are needed to overcome the limitations of past studies.
Appeal type: Medical Necessity
Decision: Upheld

A 64-year-old male enrollee requested authorization and coverage of enhanced external counterpulsation for the treatment of coronary artery disease and angina pectoris.  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 upheld the health plans denial on the basis that the requested services are not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for partial hospitalization program (PHP) services for treatment of the enrollees behavioral health condition.Findings:  The physician reviewer found that to objectively determine the appropriate level of care for the patient, the case was examined using the Child and Adolescent Level of Care Utilization System (CALOCUS). This is an accepted, national standard for determining the appropriate level of care for children and adolescents. As of 7/12/17, the patients risk of harm score is two (2), some risk of harm. The patient does not have a history of suicidal attempts or suicidal ideation. The patient does have episodes of physical aggression mostly in the context of limit setting. The patients functional status score is three (3), moderate functional impairment. The patient was initially admitted due to poor behavior and aggression. However, the notes state that the patient was gaining more confidence and demonstrating good flexibility and was attentive. His behavior had improved since admission to the PHP. The patients co-morbidity score is three (3), significant co-morbidity. The patient has intellectual disability, autism spectrum disorder, ADHD, and intermittent explosive disorder. The patient does not have any major medical problems. The patients recovery environmental stress score is two (2), mildly stressful environment. The patient has minor stressful experiences due to normative transition experiences. The patients environmental support score is one (1), highly supportive environment. The patients parents are supportive and engaged in his developmental needs. The patients resiliency score is three (3), equivocal resiliency and response to treatment. Due to the nature of autism spectrum disorder, the patient will have difficulty even with treatment. However, the patients behavior improved with treatment. The patients acceptance and engagement score is two (2), constructive. The patient has limited insight due to his condition. However, the notes state that the patient is cooperative and friendly to staff. Based on these criteria, the patient has a composite score of 16 and would meet criteria for outpatient treatment and he could have been treated in a less restrictive environment. The patient continued to need treatment for his autism spectrum disorder, ADHD, intellectual disability, and intermittent explosive disorder, but this could have been safely and adequately conducted in a less restrictive environment. Final Result: The reviewer determined that the services at issue were 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 with expertise in child and adolescent psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 31-year-old female enrollee requested authorization and coverage of arthroscopy of the shoulder for the treatment of intractable pain.  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: Upheld

An 18-year-old male enrollee has requested weekly outpatient mental health therapy for treatment of his behavioral health condition.  Findings:  The physician reviewer found that for patients with autism, deficits in general sociability, such as relatedness and reciprocity, commonly appear by age two and can persist throughout the life span. In this case, the patient particularly struggles with unrealistic expectations, and both interpersonal and social impairment, as he negotiates the developmental stage of identity formation. The requesting physician contends that a coordinated care approach, with weekly psychotherapy, is crucial to the patients successful transition to adulthood.  While it is true that multi-system and multi-disciplinary care coordination will optimize treatment gains, psychotherapy at a frequency of once a week is excessive in this setting.  Reliance on psychotherapy sessions once a week may actually undermine, rather than facilitate, the therapeutic goal of healthy and autonomous functionality. As such, the Health Plans authorization of outpatient mental health therapy every other week is reasonable and appropriate to allow for organization and coordination services, and develop unique tracking measures to optimize treatment outcomes for this patient. Considering the duration of the clinical relationship, every other week sessions would be safe and appropriate for the patient. Accordingly, weekly outpatient mental health therapy is not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for services at a residential treatment center for eating disorders. Findings:  The physician reviewer found that the Level of Care Utilization System (LOCUS) provides a reliable framework for determining the appropriate level of care for patient needing mental health treatment. Using CALOCUS, providers score patients on a scale of 1-5 using a six-pronged Dimensional Rating System. The six dimensions include: (1) risk of harm; (2) functional status; (3) medical, addictive and psychiatric comorbidity; (4) recovery environment (a. stressors and b. supports); (5) treatment and recovery history; and (6) engagement. The composite score is then used to determine the level of care needed. The patient presents a composite score of 25, which correlates with a treatment intensity level of five, which is medically monitored residential services. According to the LOCUS guideline, the patient meets the criteria for residential placement in a facility that specializes in treating patients with eating disorders. For these reasons, the requested services at a residential treatment center for eating disorders is supported as medically necessary for treatment of this patients behavioral health issues. Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in psychiatry 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

A 33-year-old female enrollee has requested UV light home therapy for treatment of her vitiligo. Findings:  Three physician reviewers found that common treatments for vitiligo include topical steroids, topical immunomodulators and phototherapy using UVA or UVB light (Lotti, et al; Eleftheriadou, et al). She has also been treated with ultrapotent topical steroids including Clobetasol cream and topical tacrolimus ointment. The medical records indicate that she has progressive disease and home therapy has been recommended given that treatments are expected to be ongoing. Given that this patient has undergone therapy with both topical steroids and topical immunomodulators and shown improvement with in-office phototherapy, the continued use of home unit is a reasonable next step. All told, the requested home phototherapy unit is likely to provide this patient with greater health benefits for treatment of her medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld

This 53-year-old woman with multiple medical problems requests growth hormone (GH) for presumed adult GH deficiency (AGHD) based on non-specific symptoms and the response to an arginine/GHRH stimulation test. She has obesity with progressive weight gain and depression treated with Lexapro. She complains of muscle pain and weakness, poor sleep, fatigue, poor concentration, and decreased libido. She is post-menopausal and on large doses of thyroxine for presumed hypothyroidism.The evaluation by her endocrinologist revealed a normal MRI of the pituitary. An arginine/GHRH stimulation test revealed a normal peak GH of 11 ng/ml. She has a suppressed TSH presumably due to the large dose of thyroxine and has an elevated LH and FSH, a normal pituitary response to inadequate estrogen replacement in menopausal patients.There is no evidence of AGHD in this patient. The diagnosis is usually made based on the clinical context, which is suggestive of some disorder of the hypothalamic-pituitary axis. Other causes for the patients symptoms could be her depression, the medication used to treat her obesity, inadequately treated menopausal symptoms or latrogenic hyperthyroidism. These must be considered and treated before undertaking a course of testing for AGHD. All tested pituitary hormones and the IGF-1 appear normal in this patient. Her MRI shows no structural lesion in the pituitary. The GH response is said to be subnormal based on a cutoff that is derived from the literature using an immunoradiometric assay. Different published assays do not completely agree on the cutoff between normal and subnormal responses. The patients response is normal. The diagnosis of AGHD is based on the clinical context, signs and symptoms, as well as the results of biochemical testing. The patients signs and symptoms are sufficiently non-specific, and GH stimulation tests sufficiently inaccurate, that it is possible to have a false positive diagnosis. As such, there is insufficient evidence growth hormone therapy is medically indicated for this patient. Therefore, I have determined that the requested therapy is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Urgent Care
Decision: Upheld

A 42-year-old male enrollee requested treatment of an injury to his left hand and wrist. 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. Based upon the documentation provided, the patients symptoms were not of sufficient severity to lead a prudent layperson to believe that he or she required treatment on an emergent basis.  This patient presented with a moderate amount of pain to his left hand and wrist. He denied any numbness or other neurologic deficit. He had not sustained any laceration. He denied any systemic symptoms such as trouble breathing, nausea, or fever. No deformity was noted. The patients symptoms were not of sufficient severity that a prudent layperson would reasonably believe the absence of immediate medical attention would place his health in serious jeopardy; serious impairment to bodily functions; or serious dysfunction of any bodily organ or part. There is no evidence the patient was in severe pain or was experiencing any symptoms that needed to be addressed on an immediate basis. All told, based on the documentation provided for review the patients symptoms did not meet prudent layperson criteria for emergency care.