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

Nature of Statutory Criteria/ Case Summary:  The enrollees parent is requesting authorization and coverage for the medication Stelara. The enrollee has psoriasis of the scalp, ears, arms, and legs. She has been treated with Taclonex, Enbrel, methotrexate, and Excimer laser. Her dermatologist noted she had severe involvement of the scalp, scaling of the ears, and scattered scaly papules on the arms and legs. The records show the enrollee has extreme anxiety with needles and would greatly benefit from biologics that require less frequent injections. The dermatology office reports that, due to the possibility of tumor necrosis factor-induced psoriasis, Humira is not preferred. Literature shows pediatric persons with psoriasis showed an excellent response to Stelara. Initial doses of the medication are administered at weeks 0 and 4, and then maintenance dosing is administered every 12 weeks. This regimen makes Stelara appealing for pediatric populations.Final Result: The reviewer determined that the requested service is medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in dermatology 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 similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the DecisionDx gene test. Findings:  Three physician reviewers found that recent literature supports the use of genetic testing of the uveal melanoma tumor in order to stratify the tumors into high and low risk for systemic metastasis. In addition, the DecisionDx test has become part of the standard of care in this patient population. The main clinical benefit of the DecisionDx test is that it determines how closely to monitor and screen the patients for metastasis. Another consideration is that although there is no therapy today to reduce the risk of metastasis, this may become available in the future. Therefore, it is important to obtain the genetic information about the tumor when available, which in the case of uveal melanoma, may only be in the early stages. For these reasons, the DecisionDx gene test performed was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: 3 of 3 reviewers determined that the testing 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: All three physician reviewers are board certified in ophthalmology 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: Overturned

A 49-year-old female enrollee has requested an electromyogram and nerve conduction study for an evaluation of her carpal tunnel syndrome. Findings:  The physician reviewer found that this patient clearly has carpal tunnel syndrome. EMG/NCV studies are typically indicated in this setting for adequate evaluation of carpal tunnel and consideration of surgical intervention. It has been more than two years since the patients last EMG/NCV studies were performed. It is medically reasonable to recheck these studies with the passage of time. In a case such as this in which a patients condition is clearly worsening, surgical therapy may now be desired. However, if significant improvement is found, the patient may wish to continue with conservative therapy. It is within the standard of care to repeat EMG/NCV studies for carpal tunnel syndrome evaluation. Such studies will be clinically useful in the ongoing management of this patients condition.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a 20-year-old male enrollee requested authorization and coverage of continued residential services for treatment of bipolar disorder and other conditions.  The health plan denied the enrollees request indicating that the requested services are 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.
Appeal type: Medical Necessity
Decision: Upheld

A 33-year-old male enrollee has requested for sub-acute detoxification level of care in a residential setting for treatment of his alcohol dependence. Findings:  The physician reviewer found that an evidence-based instrument such as the Level of Care Utilization System for Psychiatric and Addiction Services (LOCUS) is useful in determining necessary level of care to ensure a patients level of care meets their individual needs safely and effectively in the least restrictive setting possible. Per these guidelines, medically monitored non-residential services were appropriate in this situation.
Appeal type: Medical Necessity
Decision: Upheld

A 22-year-old female enrollee has requested partial hospitalization program for treatment of her  bulimia nervosa, post-traumatic stress disorder and depression, not otherwise specified.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  The medical records do not demonstrate a failed attempt at treatment at a lower level of care.  The clinical notes do not show that this patient had seen a psychiatrist for this condition prior to the disputed services, and the records do not demonstrate that she had been placed on psychotropic medications prior to her treatment at this facility.  The patients motivation was good.  She had a good support system in place which would help with the environmental stressors and would provide some external structure for controlling the compulsive exercising.  The current medical evidence does not support partial hospitalization program level of care in this clinical setting.  All told, partial hospitalization program services provided from the specified timeframe were not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

A 59-year-old female enrollee requested authorization and coverage for six hours of therapy a week (four hours of therapy and two hours of crisis calls). The Health Plan denied the request indicating that the requested therapy is not medically necessary for treatment of the enrollees behavioral health problems.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.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for skilled nursing facility (SNF) services. The records report that this patient presented with multiple fractures and was transferred to the SNF after undergoing a right hip hemi-arthroplasty. The enrollee has a right foot drop and fractures of the left acetabulum and right proximal humerus. The enrollee is unable to transfer or ambulate, and requires assistance with activities of daily living such as ambulating, toileting, and bed mobility. Furthermore, the enrollee has a Foley catheter and is incontinent of bowels. The provider noted a need to stay at the SNF. The patient continued to require skilled nursing and skilled rehabilitation services at least five days per week. Moreover, these services required the skills of technical or professional personnel such as nurses, physical therapists, and occupational therapists. Given these findings, the SNF services provided were medically necessary for treatment of this patients medical condition. 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 orthopedic 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: Upheld

The parent of a 15-year-old male enrollee has requested Tev-Tropin growth hormone (GH) for treatment of the enrollees short stature.  Findings:  The physician reviewer found that during early childhood, this patient did not meet the standard criteria for GH deficiency, as his height was not less 2 standard deviations below normal for age and gender, his bone age was not delayed, and his growth factors were normal. Based on poor results on provocative GH testing, the patient was treated with GH therapy with a modest increase in his linear growth velocity. After discontinuation of GH therapy, the patient underwent rapid pubertal progression at a young, though not precocious, age and then completed his growth after experiencing a normal pubertal growth spurt. Currently, the patients skeletal age is 17 years, which indicates that his epiphyses are fused and a fall-off in growth is expected. As such, GH therapy has no role in improving his height potential. The fact that he apparently responded to GH therapy with improvement in linear growth velocity during early childhood does not prove that he is GH deficient or that therapy is clinically indicated. Provocative GH tests have poor sensitivity and specificity for the diagnosis of GH deficiency, and even children who are not deficient may demonstrate a transient increase in growth velocity in response to GH therapy. All told, reinstatement of GH treatment will not likely improve the patients growth, as his epiphyses are already fused. Thus, the medical necessity of GH therapy has not been established as medically necessary for treatment of the patients short stature at this time.
Appeal type: Medical Necessity
Decision: Upheld

A female enrollee requested Xyrem for medical treatment of his narcolepsy with cataplexy.  Findings:  The physician reviewer found that Xyrem is not indicated for patients who are taking sedative agents. The patient is on moderate doses of chronic oxycodone which is consistently taken as the patient is refilling on a regular basis. She is also on clonazepam 1.0 mg per day. These medications can be the primary cause of excessive daytime somnolence, and can alter the results of the sleep study. Based on the clinical documentation submitted for review, Xyrem is not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Pentasa. Findings:  The physician reviewer found that there is sufficient support for the requested medication in this patients case. Per the medical evidence, 5-aminosalicylate medications such as Pentasa can be effective for the treatment of Crohns disease. Although several mesalamine derivative medications are available for the treatment of inflammatory bowel disease, each formulation results in release at distinct times and locations in the gastrointestinal tract. Pentasa is different from the alternative medications in the pH and location at which it acts. Pentasa is effective in the small intestine, which is appropriate for Crohns disease with small bowel involvement, as in this patients case. Unlike Pentasa, the formulary mesalamine alternatives are released in the colon. The other formulary alternative, budesonide, is a corticosteroid and not an appropriate long-term, first-line therapy for Crohns disease.  Additionally, the patient is known to have had bone loss, which is a known adverse effect of corticosteroids, when using Entocort (budesonide) in the past. All told, the requested medication Pentasa is medically necessary 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 with sub-specialty 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.
Appeal type: Medical Necessity
Decision: Overturned

The guardian of an enrollee has requested authorization and coverage for mental health residential treatment center services. The American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists Child and Adolescent Level of Care Utilization System (CALOCUS) provides a reliable framework for determining the appropriate level of care for children and adolescents needing mental health treatment. The patients composite score corresponds with a Level 4: Medically Monitored Community Per CALOCUS, the length of stay at this level of care can last up to 60 days.In this case, the patient received 45 days of residential treatment before his discharge. This is well within the CALOCUS guidelines for length of stay at his recommended level of care. Therefore, mental health residential treatment center services provided from his date of admission through his discharge were medically necessary for the patients medical condition. However, further clinical information is not available after his date of discharge, and based on the patients history and status upon discharge, mental health residential treatment center services provided from the date following his discharge going forward are not medically necessary for the patients condition.Final Result: The reviewer determined that a portion of the services at issue were medically necessary for the patients medical condition. Therefore, the Health Plans denial should be partially overturned.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: Medical Necessity
Decision: Upheld

Findings:  The physician reviewer found that Nature of Statutory Criteria/Case Summary:  An enrollee has authorization and coverage for consultation referral to see an autonomic specialist.Palma and colleagues state, Autonomic nervous system (ANS) dysfunction (dysautonomia), as a cause of disease is an increasingly recognized health problem, not only in the field of neurology, but also in cardiology, gastroenterology, endocrinology, urology, psychiatry, and primary care medicine. Patients may present with a myriad of symptoms including orthostatic intolerance, recurrent syncope, labile blood pressure, disorders of sweating and thermoregulation, neurogenic bladder, sexual dysfunction, gastrointestinal dysmotility, pupil abnormalities, and sleep disorders. These symptoms may, in turn, be a consequence of genetic, neurodegenerative, autoimmune, or acquired disorders. The authors also indicate, Autonomic disorders specialists require a comprehensive knowledge of the anatomy, physiology, and pharmacology of the ANS, understanding of the pathophysiology and management of acute and chronic autonomic conditions, and expertise in the performance and interpretation of clinical and laboratory evaluation of the ANS. According to the American Academy of Neurology, The role of the clinician in routine clinical practice is to undertake a thorough evaluation of clinical autonomic symptoms, perform a bedside autonomic examination, and determine if there are strong indications for further studies. In this case, the patient presents with multiple symptoms that are not suggestive of autonomic nervous system dysfunction/dysautonomia. The patient has been evaluated by multiple specialists, including neurologists. A neurological examination and diagnostic work-up have been normal. Therefore, the requested consultation referral to see an autonomic specialist is not medically necessary for treatment of the patients medical condition.Final Result: The reviewers determined that the requested service is not medically necessary for the treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

A 58-year-old male enrollee has requested proton beam therapy consisting of 45 treatments for treatment of his prostate cancer.  Findings:  Three physician reviewers found that the definitive treatment of prostate cancer is either surgery or radiation therapy. Surgery is defined as radical prostatectomy. Radiation can be delivered as either external beam or it the form of brachytherapy, which is seed implant. For modern radiation therapy, the standard of care is IMRT. Proton beam therapy is another form of radiation therapy using protons in lieu of photons. The medical literature shows no significant advantage in terms of a cure or side effects when these two modalities are compared. When proton therapy was compared with older 3-D conformal radiation, it did have fewer side effects. Thus, proton beam therapy may be appropriate, but has not clearly been shown to be superior in either outcomes or side effects for this particular cancer as compared to IMRT. In summary, the Health Plan is correct in offering IMRT as the state of the art in radiation therapy to patients who prefer radiation to surgery. In addition, there is inadequate medical justification for this patient to be treated at the requested facility with proton beam therapy. He can expect excellent results and low morbidity with IMRT.
Appeal type: Urgent Care
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested emergency room services on an emergent or urgent basis. The physician review 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 back pain radiating to his right buttock that had been present for one week. He had not suffered any recent injury. He had no neurologic deficits. The patient was described as in no distress. 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 back pain that was described as moderate. The record documents the patient as alert and in no distress. This patients symptoms were not sudden in onset. There is no documentation to suggest a prudent layperson would believe that the absence of immediate medical attention would result in serious impairment to bodily function. 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

A 37-year-old female enrollee has requested for Roux-en-Y gastric bypass surgery for treatment of her morbid obesity. Findings:  The physician reviewer found that the documentation demonstrates that this patient meets all standard, generally accepted criteria for bariatric surgery, including the National Institutes for Health guidelines. She is morbidly obese with a BMI of 48.23, has failed weight loss efforts and has completed a multidisciplinary evaluation that did not reveal any obvious dietary, behavioral or medical barriers to surgery. Thus the requested procedure is medically necessary for treatment of the patients morbid obesity and the Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for genetic testing and counseling (CPT 99205, 99215 x 3, 99358, 99354, 96040 x 4, S0562 x 8). This patient presents with bilateral sensorineural hearing loss (SNHL). The patients provider has recommended evaluation with genetic testing to assess the patient for possible congenital causes of SNHL. There is adequate support in the medical literature for use of broad genetic testing such as whole exome sequencing as part of a first-line work-up of pediatric patients with hearing loss. Kim and colleagues reported that, Mild to moderate pediatric SNHL, even if sporadic, features a strong genetic etiology and can manifest via diverse modes of inheritance. Sheppard and colleagues found that exome sequencing has an improved yield compared with clinical testing and may capture diagnoses not initially considered due to subtle clinical phenotypes. On review of the medical literature, the requested evaluation by a medical geneticist, to include complete medical history and examination targeted towards signs and symptoms of an underlying genetic condition, genetic counseling, and genetic testing are recommended for young patients with unexplained SNHL. As this patient has no prior medical history to explain her bilateral SNHL, the requested genetic testing and counseling are appropriate. For these reasons, the requested genetic testing and counseling (CPT 99205, 99215 x 3, 99358, 99354, 96040 x 4, S0562 x 8) are medically necessary for evaluation and treatment 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 pediatrics with subspecialty certifications in clinical genetics and clinical biochemical genetics 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.