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

A 42-year-old female enrollee has requested a referral to a chronic fatigue syndrome/fibromyalgia specialist for treatment of the enrollees chronic fatigue syndrome. Findings:  The physician reviewer found that to date, there is no consensus establishing a standard treatment for chronic fatigue syndrome (CFS), just as there is no accepted etiology or treating specialty as treatment outcomes are unsupported by reproducible data. With numerous patients presenting daily in clinical practice with the complaint of chronic fatigue that is oftentimes secondary to a multitude of alternative causes, it is important to rule out other causes of chronic fatigue prior to arriving at this diagnosis. Oftentimes, fatigue is attributable to any of many possible causes including depression, anemia, sleep disturbances, thyroid abnormalities and other endocrine problems, chronic pain syndrome, cardiac disease, pulmonary disorders, and chronic infections. For these patients, possible chronic viral infection and some interest in hidden endocrine abnormalities are investigated as possible etiologies. With regard to this patient, with a documented history of depression, fibromyalgia, chronic pain syndrome, and diabetes, her substantial fatigue may well be attributable to her extensive comorbidities and not in fact CFS. In addition, the information provided on this patient suggests that her providers have engaged in appropriate consultation with recognized specialists and have pursued empiric treatment trials without significant benefit. Therefore, the patients request for referral to a CFS specialist has not been shown to be medically necessary in guiding her clinical management.
Appeal type: Medical Necessity
Decision: Overturned

A 55-year-old female enrollee is requesting 16 injections of Imitrex per month for the treatment of her migraine headaches. Findings:  The physician reviewer found that the request for 16 Imitrex injections per month should be authorized since this medication is highly efficacious and has been demonstrated to reliably terminate this patients acute migraines. The requested usage of Imitrex does not represent a concern for medication overuse headaches. Furthermore, based on the information provided, there is no contraindication to the prescribed dosage.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Duexis for treatment of the enrollees rheumatoid arthritis. Findings: The physician reviewer found that the request for Duexis is not medically necessary for treatment of the patients medical condition. The medical records submitted for review fail to demonstrate that the patient has tried and failed formulary, generic nonsteroidal anti-inflammatory drugs (NSAIDs) and histamine H2-blockers. Based on the current medical literature, the request for Duexis is not supported as medically necessary. Therefore, the request for Duexis has not been established as medically necessary for treatment of the patients rheumatoid arthritis. Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in rheumatology 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 bilateral hearing aids. Findings:  The physician reviewer found that While hearing aids are helpful for patients with significant hearing loss, there is a lack of consensus on the criteria for hearing aid candidature and variability in the use of hearing aids in clinical practice among patients with mild hearing loss. In this patients case, the records document mild hearing loss that has been stable at 4,000 Hertz (Hz), with normal hearing in all other frequencies. Given that the impact of hearing loss at 4,000 Hz is minimal and would not affect speech recognition, the requested equipment is not medically indicated. Therefore, bilateral hearing aids are not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested equipment is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in otolaryngology 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 a portable oxygen concentrator. Medical literatures report that portable oxygen concentrators may be associated with better mobility for patients who are ambulatory. Khor and colleagues report comparable performance when walking between portable oxygen concentrators and traditional portable systems such as compressed oxygen cylinders. In this case, the patient is wheelchair bound and the records do not document that the patient is ambulatory. In this clinical setting, given that the current delivery system of supplemental oxygen from portable tanks is sufficient for patients who are wheelchair bound, the requested equipment is not medically indicated. Therefore, a portable oxygen concentrator is not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested equipment is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in pulmonary diseases and in sleep 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:  An enrollee has requested a power wheelchair for treatment of his Duchenne muscular dystrophy.  The physician reviewer found that durable medical equipment, such as a wheelchair, is important for the function of patients with neuromuscular diseases such as muscular dystrophy. Replacement wheelchairs are expected to be needed over time for users with muscular dystrophy due to equipment wear and tear, which can progress to the point of breakdown. The typical life expectancy of a wheelchair has generally been reported to be up to five years. Despite some advances in technology, improvements in overall wheelchair durability have not been observed. In the current case, the patient has developed progressive weakness due to muscular dystrophy. However, it is has not been established that he can safely operate a power wheelchair independently by lip-control, chin-control or otherwise any longer. Absent the ability to safely and reliably operate the power wheelchair, his needs could be met by an appropriate manual wheelchair. Thus, the requested power wheelchair is not medically necessary based on the available documentation.  Final Result: The reviewer determined that the requested equipment is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: The reviewer is board certified in 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: Medical Necessity
Decision: Overturned

A 57-year-old female enrollee has requested magnetic resonance neurography (3D computed tomography, magnetic resonance imaging, CPT code 76376 and unlisted magnetic resonance procedure, CPT code 76498) for evaluation of her thoracic outlet syndrome.  Findings:  The physician reviewer found that based on review of the available records, this patient presented with persistent symptoms leading to disability of the upper extremity following surgery. MR neurography has been proven to be useful in this clinical setting since the technique allows for imaging of the peripheral nerves. The diagnostic procedure is useful in patients with piriformis syndrome, brachial plexopathy and thoracic outlet syndrome when the peripheral nerves may be compressed or stretched, but the pathology is often not seen on conventional imaging studies. In this patients case, due to the persistence of clinical symptoms and the lack of findings on conventional imaging, the MR neurography was medically necessary for evaluation of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for progesterone suppositories and two Insulin Potentiation Therapy (IPT) treatments. The National Comprehensive Cancer Network (NCCN) standard preferred therapy for advanced staged III and IV and unresectable uterine cancer is chemotherapy with Platinum/Taxane therapy. Upfront surgery is very often necessary to make the diagnosis. However, while the estrogen receptor is prognostic in uterine cancer and presents an avenue for hormonal manipulation with progestational agents, the patients intermediate grade makes a response to such therapy less likely. In this setting of adjuvant therapy with gross residual disease, the likelihood of a meaningful response to progesterone suppositories does not justify that progesterone suppositories are medically necessary. In addition, there is no data to support the use of Insulin Potentiation Therapy (IPT) treatments in hormonal blocking therapy. Accordingly, progesterone suppositories and two Insulin Potentiation Therapy (IPT) treatments are not medically necessary for treatment of the patients medical condition.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 obstetrics and gynecology, with subspecialty certification in gynecologic oncology. 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 59-year-old male has requested coverage for proton beam therapy for treatment of his prostate cancer.   Findings:  The physician reviewer found that this patient is categorized into the low risk group as defined by the medical literature (Zietman, et al). The management of low risk disease can include active surveillance, surgery, prostate brachytherapy, or external beam radiation. Based on the recommendations from Kuban and colleagues, dose escalation resulted in improved freedom from biochemical and clinical progression and can be achieved with brachytherapy, intensity modulated radiation therapy (IMRT) with or without image guided radiation therapy (IGRT), or proton beam therapy. Based upon the size of the patients gland being 138 grams, brachytherapy is not advised. Further, there is a paucity of studies demonstrating proton beam radiation therapy to result in improved health outcomes beyond that expected with standard therapies. There are no randomized trials comparing protons versus IMRT. For these reasons, the data do not currently support any definitive benefit of proton beam therapy over other forms of high dose conformal radiation and therefore is not medically necessary for treatment of the patients prostate cancer.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential treatment center services. The submitted documentation fails to demonstrate the medical necessity of the services at issue. This patient was admitted to the treatment center due to some oppositional behaviors as well as some depressive symptoms. His mood and depression symptoms appeared mild in nature. On his intake evaluation, he and his family reported symptoms of autistic spectrum disorder. He was not noted to have aggressive behaviors during his stay.  He appeared to have some level of rigid thought process which is typical of patients with autistic spectrum disorder. The patient denied serious depression or anhedonia during his stay. There was no documentation of debilitating anxiety or psychosis. The documentation does not support failure of intensive outpatient therapy, partial hospital program therapy or cognitive behavioral therapy. The progress notes indicate that the patient had relational issues with his family as documented in his initial psychiatric evaluation. Initial psychiatric recommendations included working on parental communication in psychotherapy.  It is not clear what type of family therapy the family had engaged in on outpatient basis. Functional family therapy appeared to be indicated in this case and has proven highly successful in decreasing violence, drug abuse, conduct disorder and family conflict. Functional family therapy is typically administered on an outpatient basis. The submitted records indicate that this type of treatment would have been appropriate for the patient and his family on an outpatient basis. The evidence base regarding childrens mental health treatment has shown that treatment outside of a residential setting is effective and appropriate and is as beneficial as residential treatment center programs. Due to his lack of severe symptoms and dangerous behaviors, less restrictive care was medically appropriate. Therefore, residential treatment center services were not medically necessary 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 with sub-specialty certification 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: Urgent Care
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested emergency room services on an emergent basis or urgent basis. Findings:  The physician reviewer found that review of the submitted documentation demonstrates that a prudent layperson would not have sought immediate medical attention on the date in question. Upon review of the submitted medical records, the patient presented with a foot injury that was sustained a significant time period earlier.  Although the patient rated his pain above average, there was no history of a break in the skin or puncture wound. In addition, there were no signs of inflammation or possible infection. There was no sign of vascular or nerve injury. Based on the patients presenting complaints and symptoms, a prudent layperson in this circumstance would not reasonably believe he was suffering from a serious medical condition. In sum, the patient was not suffering from a serious medical condition that was likely to place the patients health in serious jeopardy, cause serious impairment to body functions or cause serious dysfunction to a body organ or part. Thus, the services did not meet prudent layperson criteria for emergency care. Further, it has not been established that criteria for urgently needed services were met on the date in dispute. In this case, the patient presented with foot injury with delayed presentation. Based on the documentation submitted for review a prudent layperson in a similar situation would not have believed immediate medical attention was necessary to prevent serious deterioration of ones health. In sum, based on the patients clinical presentation the patient did not meet prudent layperson criteria for urgently needed services. As such, the Health Plans denial should be upheld. Final Result: The reviewer determined that the patients symptoms did not meet prudent layperson criteria for emergency care or urgently needed services. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: The reviewer is board certified in emergency 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: Overturned

Findings:  The physician reviewer found that The patient has requested authorization and coverage for Euflexxa injections (J7323) to the left knee. Evidence from systematic reviews and randomized controlled trials indicate that although viscosupplementation may relieve knee pain in some patients with osteoarthritis, data has not established which patients will benefit. Guidelines from the American Academy of Orthopedic Surgeons (AAOS) indicate that the data on safety and efficacy of viscosupplementation remain inconclusive. As such, the AAOS does not currently recommend viscosupplementation as routine treatment for osteoarthritis of the knees. Viscosupplementation is reserved for patients with a history of lasting benefit from prior injections and in cases where the remaining options are limited. In this case, there is a history of 60% relief from prior viscosupplementation with a series of three Euflexxa injections in 2019. The provider reported that the patient experienced relief that lasted seven months. Given this support, the requested Euflexxa injections (J7323) to the left knee are medically necessary for treatment of this patient.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.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested continued skilled nursing facility services and stay, including rehabilitative physical therapy for treatment of the enrollees medical condition.  Findings: The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services. There were no identified skilled nursing needs including rehabilitative physical therapy for this patient. The patients care needs can be appropriately met at an alternate level such as with home based services or at a custodial level until her weight-bearing status is advanced. The patient is status post multi-trauma with orthopedic precautions including touchdown weight-bearing on the right which can be considered as even more restrictive than non-weight-bearing and is intended to prevent both traction and compressive forces across the limb. The patients orthopedic precautions are ongoing and will likely continue at least until the end of July. The records submitted indicate that the patient has reached a plateau at her level of function consistent with her orthopedic injuries and precautions. The expectation of significant functional progress in a reasonable and predictable time cannot be established. All told, the requested services 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: Medical Necessity
Decision: Upheld

The mother of a nine-year-old male enrollee requested authorization and coverage of continued physical therapy for treatment of the enrollees medical condition. The Health Plan  denied the request indicating that the requested therapy is not medically necessary for the enrollees rehabilitation.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested therapy is not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

A 40-year-old female enrollee has requested a bariatric surgery consultation for the treatment of her medical condition status post gastric bypass surgery. Findings:  The physician reviewer found that this patient has a medical condition that is correctable with the appropriate surgical procedure. While details about the initial procedure are not known, the patient has obviously experienced a poor outcome with weight regain, which is a complication of the gastric bypass procedure. Further, the patient reports that she has dumping syndrome. This is also a complication of the initial gastric bypass operation that requires surgical treatment. A bariatric surgery consultation is medically appropriate and indicated to evaluate the patient and educate her on the available surgical options.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/ Case Summary:  The enrollee requested reimbursement for laboratory services for hyperlipidemia. Findings:  The physician reviewer found that the enrollee indicates she needed the labs to check her cholesterol level. Results of the testing revealed LDL-cholesterol 90, HDL cholesterol 53, non-HDL cholesterol 119, total cholesterol 172, triglycerides 191, apolipoprotein B 78, lipoprotein (a) 474, LDL particle number 1007 with peak size 219.2 and pattern A. This enrollee does not relate a history of cardiovascular disease and records submitted indicate that Cardio IQ testing was performed six times over the last few years. According to the medical literature there is no benefit recommendation for lipoprotein and apolipoprotein assessments, citing absence of evidence that these measurements provide additional productive value beyond that obtained by measuring the standard fasting lipid panel. This testing does not have support from the national cardiovascular societies. There is insufficient evidence in the record supporting the benefit of this testing for this enrollee over the standard fasting lipid profile. Moreover, treatment of hyperlipidemia is based on the standard lipid profile. Final Result: Three of the three reviewers determined that the requested services are not likely to be more beneficial than any available standard therapy for treatment of the enrollees medical condition. Credentials/Qualifications: Three reviewers are board certified in Cardiology and are actively practicing.  All three 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.