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

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for inpatient psychiatric hospitalization level of care services. Per the American Society of Addiction Medicine (ASAM) criteria, this patient met Level 4 criteria for inpatient psychiatric hospitalization level of care services. ASAM criteria focuses on six dimensions to determine the appropriate level of care, which includes: (1) intoxication and withdrawal potential; (2) biomedical conditions; (3) emotional, behavioral and cognitive conditions; (4) readiness to change; (5) relapse, continued use, or continued problem potential; and (6) recovery environment. For dimension 1, the patients risk for withdrawal was elevated given uncertainty regarding opioid used and when last used. She required several doses of Ativan and Hydroxyzine for anxiety, and multiple doses of Zofran for nausea, thereby further supporting the providers concern for the patients safety and monitoring for suicidality, despite the fact that she had not reported a specific plan. The patients history suggests she was in crisis when she presented to the emergency department after having suicidal ideation for two days, worsening anxiety, depression, and inability to function at home or care for her infant daughter. On evaluation, the provider placed her on observation to ensure her safety given her suicidality. The patients withdrawal management required treatment at Level 4, with 24-hour monitoring every 30-60 minutes until improvement begins, then every two hours. For dimension 2, the patient complained of concomitant abdominal pain, nausea, myalgia and headache, which warranted 24-hour observation and stabilization. At the end of her admission, the patient was deemed stable for transfer and step-down to a residential treatment center (RTC). For dimension 3, the patient reported inability to control her opiate use without 24-hour psychiatric management and support. Overall, her co-occurring anxiety, social stress, and other social stressors made it improbable that she could control her impulses outside this level of care. Per ASAM Level 4 guidelines, this patient met criteria from dimensions 1 through 3, which support treatment at the inpatient psychiatric hospitalization level of care. Given these findings, the inpatient psychiatric hospitalization level of care services were medically necessary for treatment of this patient. Final Result: The reviewer determined that the services at issue were 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 with subspecialty certification in addiction medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for proton beam radiation therapy services. The submitted documentation does not support the medical necessity of the requested services. Per the medical literature, there is a lack of clinical data suggesting that proton beam radiation therapy is associated with a clinical benefit in the treatment of prostate cancer. Vapiwala and colleagues report that in a large, multi-institutional analysis of 1,850 patients with early-stage prostate cancer, treatment with moderately hypofractionated intensity-modulated radiation therapy and proton beam therapy both resulted in low rates of toxicity. The authors further noted that no difference was seen in late genitourinary and gastrointestinal toxicity between the modalities during long-term follow-up. The American Society of Radiation Oncology (ASTRO) notes, Proton beam therapy for primary treatment of prostate cancer should only be performed within the context of a prospective clinical trial or registry. In this clinical setting, given the lack of evidence to support the use of proton beam therapy, the requested services are not medically indicated. Therefore, proton beam radiation therapy services are not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested services are not medically necessary for the treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in radiation oncology 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 46-year-old female enrollee has requested a consultation with a corneal specialist for treatment of her recurrent pterygium. Findings:  The physician reviewer found that the available medical literature indicates that the correction of a problem, such as this patients, would require intervention by a strabismus surgeon, to relieve the restriction of lateral movement and unless the strabismus surgeon is also skilled in ocular surface reconstruction, it is also indicated to have a corneal specialist collaborate with the strabismus surgeon. No evidence has been provided that the Health Plan has authorized a referral to a strabismus surgeon who is skilled in ocular surface reconstruction. Therefore, a referral to a corneal specialist is medically appropriate and indicated for this patient.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a one-year-old female enrollee has requested intravenous immunoglobulin (IVIG) for treatment of the enrollees neutropenia. Findings:  The physician reviewer found that the records indicate this patients IgG level and specific antibody levels to the pneumococcal antigens are in the normal range. Although the patient improved following an IgG infusion, this was unlikely the cause for her improvement. Her lack of response to the varicella, hepatitis and rubella is also not an indication of a B cell dependent response. For these reasons, the requested IVIG is not medically necessary. Although this patient may have an immunodeficiency, the records suggest her B cell dependent antibody responses and total IgG are sufficient and IVIG would be unlikely to improve her condition. All told, the requested IVIG is not supported as medically necessary for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

A 51-year-old male enrollee requested authorization and coverage of the medication thalidomide for the treatment of prurigo nodularis.  The health plan denied the enrollees request indicating that the requested treatment is considered experimental.Three physician reviewers performed an experimental/investigational Independent Medical Review.  Two of the three physician reviewers concluded that the requested thalidomide is likely to be more beneficial for treatment of the enrollees prurigo nodularis than any available standard therapy.  Because two of the three physician reviewers concluded that the requested treatment is likely to be more beneficial for treatment of the enrollees medical condition than any available standard therapy, the review organization overturned the health plans denial.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a six-year-old female requested authorization and coverage for speech therapy for treatment of the enrollees Duane Syndrome/Apraxia of Speech.  The health plan has denied this request.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer overturned the health plans denial on the basis that the requested therapy is medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for 12 sessions of physical therapy. The management of chronic benign musculoskeletal pain affecting the neck, shoulders, and back can include pharmacological agents, rehabilitation, psychological treatment, and invasive approaches. The aim of rehabilitation is to reduce pain and impairment, while improving quality of life (Urits, et al.). Formal rehabilitative interventions are rendered, in conjunction with education, towards a goal of self-management, independent exercise, and remaining active (Bier, et al.; Chou, et al.). However, the benefit of prolonged exercise and formal modalities in a formal therapy setting has not been demonstrated in the medical literature. Prolonged formal therapy in the chronic pain setting has not been shown to yield improved patient health outcomes over independently pursued exercises and independently rendered interventions and topical treatments. With respect to cervical radiculopathy and radicular symptomatology, there is a paucity of high-quality evidence informing treatment for cervical radiculopathy, including with respect to the efficacy of exercise and therapy interventions such as manual therapy (Thoomes). This patient has a history of chronic neck pain, radicular pain into the arms, and back pain. She reports that her symptoms worsen when she is not participating in physical therapy. On review of the available records, there is a lack of indication that the patient has any impairments that preclude full transition to an independent program to include exercise and modalities that can be applied independently to manage her symptomatology. She underwent a series of physical therapy before starting another course. Physical examinations have consistently shown no neurological deficits. Based on current medical literature, there is no reasonable expectation that the patients clinical course or outcomes will improve with formal physical therapy over an independent program. Given these findings, the requested 12 sessions of physical therapy 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 physical medicine and rehabilitation 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 reimbursement for Smartpill procedure (CPT 91112, gastrointestinal transit and pressure measurement, stomach through the colon, wireless capsule, with interpretation and report). Findings:  The physician reviewer found that his patient presented with complaints of constipation, fecal incontinence, urgency, and a history of Parkinsons disease. The current peer-reviewed medical literature does not recommend use of the Smartpill for evaluation of symptoms such as constipation, fecal incontinence, and urgency. The Agency for Healthcare Research and Quality (AHRQ) conducted a systematic review on the effectiveness of the Smartpill compared with other available tests for the evaluation of gastric and colonic motility. The AHRQ found that the strength of evidence regarding the ability of Smartpill to detect slow-transit constipation was low. Similar findings have been reported in the medical literature (Lembo, et al.). This use of Smartpill has also been evaluated in studies in patients with Parkinsons disease. However, there is a paucity of peer-reviewed medical literature demonstrating improved patient health outcomes with use of the Smartpill in the management of constipation, fecal incontinence, or urgency in patients with Parkinsons disease. All told, the Smartpill procedure (CPT 91112, gastrointestinal transit and pressure measurement, stomach through the colon, wireless capsule, with interpretation and report) was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.   Findings: Two of the three physician reviewers found the Smartpill procedure (CPT 91112, gastrointestinal transit and pressure measurement, stomach through the colon, wireless capsule, with interpretation and report) was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: The reviewers determined that the services at issue were 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: Physician reviewer 1 is board certified in internal medicine with subspecialty certification in gastroenterology and is actively practicing. Physician reviewer 2 is board certified in internal medicine with subspecialty certification in gastroenterology and is actively practicing. Physician reviewer 3 is board certified in internal medicine with subspecialty certification in gastroenterology and is actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 50-year-old female enrollee requested authorization and coverage of uterine artery embolization (UAE) for the treatment of uterine fibroids.  The health plan denied the enrollees request indicating that the requested treatment is experimental.Three physician reviewers performed an experimental/investigational Independent Medical Review.  Each of the three physician reviewers concluded that a uterine artery embolization (UAE) is not likely to be more beneficial for treatment of the enrollees uterine fibroids than any available standard therapy.  Because all three physician reviewers concluded that the requested treatment is not likely to be more beneficial for treatment of the enrollees medical condition than any available standard therapy, the review organization upheld the health plans denial.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested psychiatric intensive outpatient program 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. During the dates of service at issue, the patient denied depression and showed no indication of suicidal or self-injurious desires.  He showed improvement and progression in personal functioning.  Although his baseline behavior of avoidance continued, this appeared to be a hardened, ingrained pattern of coping with his emotions that could continue to be dealt with on an outpatient basis.  He had become more open and honest in his communication.  He was motivated and appeared to be working the program.  He was medically and psychiatrically stable.  He had support systems in place.  No new problems had arisen.  Although he continued to struggle with his emotions and required further treatment to help him develop and solidify coping skills, this did not require the structured environment of an intensive outpatient program setting.  All told, psychiatric intensive outpatient program services were not medically indicated for the treatment of this patient.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 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Emend 125 mg for treatment of the enrollees medical condition. Findings:  The physician reviewer found that the documentation provided does not support the medical necessity for the medication at issue in this clinical setting. The medical literature recommends control of postoperative nausea as an important principle in facial aesthetic surgery. One of the anesthesia requirements for facial cosmetic surgery includes prevention of postoperative nausea and vomiting. The patient was prescribed Emend 125 mg (one tablet) for postoperative nausea and vomiting following the patients rhinoplasty and facelift.  However, in this patients case, the 125 mg tablet of Emend exceeds the recommended 40 mg tablet as indicated on the medication labeling for postoperative nausea and vomiting. In addition, Emend is recommended to be given one to three hours prior to anesthesia. Per the record, the provider prescribed the medication to be taken the night before. There was insufficient documentation provided by the treating surgeon to justify 125 mg tablet of Emend to be taken the night before the surgery. Therefore, Emend 125 mg administered was not medically necessary for the treatment of this patients medical condition. Final Result: The reviewer determined that the medication at issue was 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 plastic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 31-year-old transgender female enrollee has requested  facial laser hair removal for treatment of her gender identity disorder.  Findings:  The physician reviewer found that the removal of male pattern facial hair via laser surgery is necessary to create a normal appearance to the extent possible. As noted by Preston and colleagues, laser hair removal resulted in 77% satisfaction rate among study participants. These results are superior to satisfaction rates achieved with electrolysis or waxing. It is the consensus in the dermatology community that hair removal via laser surgery is more successful than any other method including electrolysis. As such, the proposed laser surgery is necessary to correct the presence of abnormal facial hair in this patient. Based upon the foregoing, the requested facial laser hair removal is considered reconstructive surgery as defined above and therefore is medically necessary for treatment of the patients gender identity disorder.
Appeal type: Medical Necessity
Decision: Upheld

A 23-year-old female enrollee has requested hearing aids or a hearing device for treatment of her difficulty hearing. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested equipment.  Based on the clinical responses of the multiple hearing tests that were recorded, hearing aids or a hearing device are not medically indicated.  Over the prior two years, this patient has had multiple audiology evaluations which confirmed that the pure-tone averages were essentially normal.  Per the submitted documentation, multiple hearing tests performed over a two-year period do not show any evidence of any substantial hearing impairment.  All told, the requested hearing aids or a hearing device are not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

A male enrollee requested Serostim for medical treatment of his human immunodeficiency virus (HIV) associated wasting.  Findings:  The physician reviewer found that Serostim is recombinant human growth hormone.  Per the current medical evidence, growth hormone should be reserved for those patients with severe wasting when other treatments have not been effective.  In this case, the patient has a normal body mass index of 23.1.  The documentation states he has failed treatment with Megace for HIV associated wasting syndrome.  However, the records do not document that he has been advised on the importance of exercise, had a testosterone level checked or been tried on alternative medications besides Megace.  There is a lack of support for the requested medication in this clinical setting.  All told, Serostim is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for esophageal impedance test and endoscopy. The recent American Society for Gastrointestinal Endoscopy (ASGE) guidelines recommend endoscopy for the evaluation of upper gastrointestinal symptoms such as gastroesophageal reflux which are refractory to proton pump inhibitor (PPI) therapy, as documented in this case. The ASGE states that when combined with pH testing, impedance can identify whether the refluxate is acidic, and can provide correlation between reflux episodes and symptoms to help guide management. This data can be useful in patients with persistent symptoms on PPI therapy who have nonacid reflux as a cause for symptoms. The American College of Gastroenterology (ACG) guidelines for the management of gastroesophageal reflux disease (GERD) state that reflux monitoring can be performed by impedance-pH testing. The ACG noted that, Patients found to have abnormal amounts of non-acid reflux on PPI therapy with good symptom correlation may be considered for surgery. For patients who do not respond to PPI, diagnostic testing with impedance and/or pH monitoring are reasonable to exclude continued acid or weakly acid reflux, and can make the diagnosis of non-acid reflux possible. This patient has ongoing reflux symptoms despite long-term PPI treatment. In addition, there is a lack of esophagitis or other findings on esophagogastroduodenoscopy (EGD). Given these findings, the requested esophageal impedance test and endoscopy are medically necessary for evaluation of this patient. Final Result: The reviewer determined that the requested services 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 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.