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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for continued inpatient hospitalization. The records provided for review document that this patient was admitted to the hospital with confusion and possible sepsis. He continues to receive IV antibiotics for discitis of L4-5 and possible C4-5. His confusion was determined to be due to hepatic encephalopathy with delirium and weakness. At the time of admission, it was unclear if the patient had ongoing sepsis due to the discitis or another cause. The providers recommended continuing the patient on IV Cefazolin for six additional weeks. He did not have any active bleeding but was persistently anemic and therefore received a transfusion of one unit of blood. The patients white blood count was normal and there were no significant electrolyte disturbances. The patient was confused and having visual hallucinations. He was treated for possible Wernicke encephalopathy with high dose thiamine. He slowly had improved by the time of proposed discharge from the hospital. The patient was hemodynamically stable and afebrile. He was voiding appropriately and tolerating an oral diet. He no longer has a need for IV fluids and has a peripherally inserted central catheter (PICC) line for administration of antibiotics. He continues to have vague complaints of pain treated with oral medications. Treatment with Abilify has helped improve the patients mood and confusion. Recent progress notes indicate that the patient has been at the same baseline with confusion for the last couple of weeks, but he is more cooperative with Abilify and he has been participating with physical therapy. The patient was hemodynamically stable. He was voiding appropriately and was tolerating oral pain medications and an oral diet. He continues to require IV antibiotics and skilled rehabilitation services for continued weakness. However, these services can be provided at a lower level of care. All told, the requested continued inpatient hospitalization is 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 internal medicine with expertise in skilled nursing facilities 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for bilateral digital breast tomosynthesis who presented for a breast examination. Findings:  Three physician reviewers found that breast tomosynthesis is a technique that was developed several years ago as a problem solving adjunct to routine mammography.  Applying the same basic concept as computed tomography scanning, the logic is that by separating the various layers of breast tissue, one can better detect abnormalities. This has been shown to be most useful in the evaluation of dense breasts.  But in terms of surveillance in patients who have had breast cancer, studies have demonstrated that when digital breast tomosynthesis was applied in a study, screening sensitivity had improved. Operative bed recurrence could be more confidently excluded from scarring, which reduced the number of indeterminate findings by proving either a definite benign or malignant diagnosis.  Final Result: The reviewers determined that the service at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: Physician reviewers 1, 2, and 3 are board certified in diagnostic radiology 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 parents of a 17-year-old female enrollee have requested for residential treatment services for treatment of the enrollees eating disorder. Findings:  The physician reviewer found that at the time of admission the patient was in need of 24-hour supervision because her eating had significantly decreased, she had stopped outpatient treatment and she was exercising several hours a day. The patient had primary amenorrhea, but her heart rate was normal at the time of admission. She was said to be mildly malnourished. Her blood chemistries and EKG showed no abnormalities. In the residential treatment facility, the patient was reasonably compliant but did refuse all medications. She was not psychotic, suicidal or homicidal and she was not medically unstable. Her provider, stated that the patient was doing well and had not recently engaged in any unhealthy behaviors. The patient was said to have an obsessive quality to her thinking and poor insight, but denied symptoms of obsessive compulsive disorder. Her mood was described as good and her anxiety was noted to be stable. The provider further indicated the patient was compliant and has no behaviors of concern. However, there was previously stated concerns that the patient could not maintain her improvements outside the structure of residential treatment. The patients weight was almost at her ideal body weight and there were no indications she needed intensive professional supervision on a 24-hour basis. By that point, the patient could have been safely and effectively treated at a lower level of care.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 68-year-old male enrollee with chronic obstructive pulmonary disease and asthma. He received symptomatic relief with the use of a nebulizer.  Primarily because of his travels, he requires a portable battery-powered nebulizer. He has requested reimbursement for a portable nebulizer from this Health Plan. The Health Plan provides coverage for standard portable nebulizers. The Health Plan has denied the reimbursement request for the battery-powered nebulizer. The patients available history affords no mention of his current condition or the overall severity of his asthma. There is no mention of the specific reason the patient uses a nebulizer in preference to the more standard metered dose inhaler (MDI). The standard of care for asthma is to use rescue therapy for management of acute symptoms. Generally, it is no longer advocated to use short acting bronchodilators for maintenance therapy. In terms of efficacy, the nebulizer affords no advantage over MDIs. Generally MDIs are preferred due to their portability and availability for acute symptoms. In this situation, the enrollee has overcome this obstacle by using a battery-powered portable nebulizer. Unfortunately, the clinical history makes no mention of why the patient is managed with a nebulizer in preference to an MDI. The Plan covers a portable nebulizer; it is not the battery-powered unit purchased by the patient. There is no dispute that rescue therapy is medically necessary and must be available when symptoms present. Therefore, portability is important and medically necessary. However, there is no evidence that the patient required a battery powered nebulizer or that he could not have been safely and effectively treated with appropriate alternatives. Because there is no evidence that alternative treatments were contraindicated, I have determined the equipment at issue was not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested digital breast tomosynthesis for evaluation of the enrollees risk for breast cancer.  Findings: Two physician reviewers found that Tomosynthesis is a technique that was developed several years ago as a problem solving adjunct to routine mammography. Applying the same basic concept as computed tomography (CT) scanning, by separating the various layers of breast tissue, one can better detect abnormalities. This patient has breasts that have been described as being extremely dense. While one could make the argument that her mammogram has not changed since the last study, it is specifically those patients who have dense breasts that can benefit most from tomosynthesis. The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor. Thus, in this clinical setting, the use of the digital breast tomosynthesis is likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: Two reviewers determined that the diagnostic procedure at issue is likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: All three physician reviewers are board certified in diagnostic radiology and are actively practicing. The reviewer are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 63-year-old male enrollee has requested a Laparoscopic Adjustable Gastric Banding System for treatment of his obesity.   Findings:  The physician reviewer found that based on the records provided, the patient meets the criteria set by National Institutes of Health (NIH) for weight loss surgery. In addition, Choi and colleagues applied the standards from the NIH, which recommend bariatric surgery for patients with a BMI of greater than 40 or greater than 35 with significant co-morbidities. The authors observed positive health outcomes in patients with a BMI between 30 and 35 with conditions such as hypertension, diabetes, GERD, and obstructive sleep apnea. Given that this patient has a BMI over the recommendation for bariatric surgery and has significant co-morbid conditions including hypertension, sleep apnea and GERD, the requested surgery has been established to be medically necessary for management of his health issues.
Appeal type: Experimental/Investigational
Decision: Overturned

The parent of a 10-year-old female enrollee has requested  for a Magnetoencephalograpy (MEG) for evaluation of the enrollees seizures.   Findings:  Two physician reviewers found that the medical experience with MEG is increasing and there is a substantial amount of literature about the usefulness and advantages of MEG over traditional methods of preoperative evaluation for neurosurgical treatment of intractable seizures. Many institutions depend on MEG for these type of evaluations and believe that it is rapidly becoming the standard.
Appeal type: Experimental/Investigational
Decision: Upheld

A 60-year-old female enrollee has requested for a breast MRI for evaluation of her breast condition. Findings:  Three physician reviewers found that the report could not rule out ductal carcinoma or papillary tumor, and an MRI was recommended. The American College of Surgeons has issued guidelines for the use of breast MRI.  It is used to look for breast cancer recurrence or to evaluate multicentric disease.  It is used in some cases for assistance in treatment.  It is used for screening high-risk women.  It is also used to evaluate indeterminate findings on ultrasound, mammography, and examination.  This patient has suspicious findings on ultrasound.  However, ductogram or biopsy would be more useful than MRI. MRI findings would not change the patients clinical management and would not provide a definitive diagnosis.
Appeal type: Medical Necessity
Decision: Overturned

A 32-year-old female enrollee has requested for Guardian RT continuing sensors for treatment of her diabetes.   Findings:  Three physician reviewers found that the data is clear that the lower the A1C, the lower is the risk of microvascular complications. The requested equipment is approved for the use for which it has been requested and has sufficient data to support its efficacy. Furthermore, this patient has obtained objective benefit from the device.
Appeal type: Experimental/Investigational
Decision: Overturned

A 55-year-old male enrollee has requested for pulmonary vein isolation and ablation for treatment of his atrial fibrillation. Findings:  Three physician reviewers found that ablation was not offered as a first-line treatment, and is being considered because of persistent and refractory symptoms. The patient is on a calcium channel blocker and Rhythmol therapy was unsuccessful. Long-term amiodarone in a middle aged patient is problematic given its potential toxicity. While pulmonary vein ablation is not superior to pharmacologic therapy, it can improve symptoms in those highly symptomatic patients intolerant of therapy.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for hernia surgery on or before 12/11/20. Ramanan and colleagues note that observation is an acceptable management strategy for asymptomatic and minimally symptomatic inguinal hernias. However, in this case, the patient has a symptomatic inguinal hernia, which he reports as increasingly painful and interfering with activities of daily living. In this clinical setting, the requested service is medically indicated. Therefore, hernia surgery on or before 12/11/20 is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested service 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 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: Experimental/Investigational
Decision: Overturned

An 18-year-old male enrollee has requested Botox injections for the treatment of his intractable migraine headaches. Findings:  Three physician reviewers found that this patient has a severe secondary headache disorder and has been tried on all of the usual acute and preventive migraine medications without improvement. Botox has a unique mechanism of action and most likely works by blocking peripheral trigeminal nerve nociceptive input. While the vast majority of literature involves Botox in chronic migraine, Botox has also shown results in a variety of intractable headache and facial pain disorders including trigeminal neuralgia, occipital neuralgia and cluster headache. The records from the specialist suggest the patients headaches are related to intracranial pressure dynamics but multiple surgical procedures have failed to provide anything more than temporary relief. Given the intractable and severe nature of the headaches, the patients failure to respond to extensive trials of standard therapy, and clinical literature that suggests a variety of atypical headache disorders may respond to Botox, Botox is likely to be more beneficial for this patient than any available standard therapy.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the breast tomosynthesis performed.Findings:  The physician reviewer found that the patient is a female who presented on  the date of dipute for a routine screening  mammography which included tomosynthesis. The patient has requested reimbursement for the breast tomosynthesis performed on the date of dispute. The Health Plan has denied this request as investigational. There is sufficient support in the peer-reviewed literature for the diagnostic procedure at issue in this clinical setting. According to a study, the addition of breast tomosynthesis reduces false positives and increases cancer detection when compared to two-dimensional mammography alone. Moreover, Detection rates, including those for invasive and in situ cancers, were 6.1 per 1000 examinations for mammography alone and 8.0 per 1000 examinations for mammography plus tomosynthesis . Given the support above, the breast tomosynthesis performed on the date of disput was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: The reviewers determined that the service at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewers 1, 2 & 3 are board certified in diagnostic radiology and are actively practicing. The reviewers are all expert sin the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Urgent Care
Decision: Upheld

The parent of a two-year-old female enrollee has requested emergency services for the treatment of the enrollees ear pain and congestion. Findings:  The physician reviewer found that the prudent layperson standard for an emergency requires that the patients condition be of acute onset and of such severity that a prudent layperson would believe the patients health to be in jeopardy without immediate medical attention. This patient awoke crying and complaining of earache. She did not receive any pain medication at home. She presented to the Emergency Department in no acute distress. Her vital signs including her temperature were normal. Her otitis media could have been managed safely in an outpatient setting. She could have received pain medicine at home and been seen safely the next day by her primary care physician. Her condition was stable in the Emergency Department. The submitted documentation does not establish the presence of a condition that would cause a prudent layperson with an average knowledge of medicine to reasonably expect that the patients health was in jeopardy without immediate emergency care.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for functional electrical stimulation NOS. The Health Plan has denied this request indicating that the services at issue were considered investigational for treatment of the enrollees relapsing remitting multiple sclerosis. Findings:  According to current published evidence within peer reviewer literature, it is insufficient to conclude that functional electrical stimulation (FES) will improve health outcomes in patients with multiple sclerosis. The studies published to date have had significant methodological drawbacks and were case series rather than well power-randomized trials and have also failed to present conclusive evidence regarding whether FES improves treatment outcomes in patients with MS, particularly when compared to other treatment modalities. The current literature is also limited and demonstrates an incomplete assessment of net benefit versus harm and additional research is necessary to permit conclusions on the benefit of the requested device or technology in aiding ambulation in patients with MS. Therefore, the functional electrical stimulation NOS was not likely to be more beneficial for treatment 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/QualificationsAll three reviewers are board certified in neurology 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

An enrollee has requested authorization and coverage for HP Acthar Gel injections, 80 units three (3) times weekly.The medical literature does not support that the requested medication is medically necessary. The current recommendation for the treatment of sarcoidosis is corticosteroids followed by steroid sparing agents (Wijsenbeek, M., and Culver, D.; Liss, D., et al.). There are currently no national guidelines, randomized controlled trials or large cohort studies demonstrating the superiority or non-inferiority of Acthar to corticosteroids (Metersky, M.; Liss, D., et al.). In this case, the patient has end-stage lung disease from sarcoidosis with pulmonary arterial hypertension. The patient has not responded to prednisone, and more potent steroids were not recently tried due to an assumed lack of response. Current medications include Imuran, Revatio, Tracleer and Tyvaso. The current medical literature, however, does not support that Acthar is safe and effective as treatment for pulmonary sarcoidosis. Accordingly, the requested HP Acthar Gel injections, 80 units three (3) times weekly, are not medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested medication is not medically necessary to treat the patients medical condition. Therefore, the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:   An enrollee has requested  Xolair for treatment of her severe asthma.  The physician reviewer found that the submitted documentation supports the medical necessity of the requested medication.  The Health Plan noted that the patients IgE level was over the recommended range for treatment with Xolair.  However, there are studies that show Xolair treatment is beneficial and safe for patients with IgE levels higher than 700 IU/mL.  There is sufficient support for the requested medication in this clinical setting.  This patient has shown significant clinical improvement with the use of Xolair, as her asthma symptoms improved with this medication.  All told, the requested medication Xolair is medically indicated 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 and allergy and immunology 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.