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

A 50-year-old female enrollee has requested Adderall, 150mg per day for treatment of her attention deficit disorder. Findings:  The physician reviewer found that side effects of stimulants are dose-dependent and include increased blood pressure. Side effects can often be managed by lowering the dose. Rostain also notes that attention deficit/hyperactivity disorder medications may increase blood pressure and heart rate in adults. In this patients case, the use of Adderall, 150mg per day is contraindicated in light of the associated blood pressure risks.
Appeal type: Medical Necessity
Decision: Upheld

An enrollee has requested authorization and coverage for Humira 40 mg/0.8 ml pen for treatment of the enrollees medical condition. Findings:  The physician reviewer found that the records document a history of rheumatoid arthritis, scleritis and side effects from chronic steroid use.  The most recent visit notes inflammation, although the examination in the records fails to demonstrate this.  It is unclear from the records how much methotrexate the patient is taking.  Per the medical evidence, methotrexate is effective in most patients with moderate to severe rheumatoid arthritis.  For patients using methotrexate, it may take up to three months to see the full effects.  In this patients case, it is unclear what dose the patient is on and how active her disease is.  As such, the medical records fail to demonstrate that the patient has received an adequate trial of methotrexate prior to adding the anti-tumor necrosis factor agent.  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: Physician reviewer number one 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: Experimental/Investigational
Decision: Upheld

A 56-year-old male enrollee has requested intensity modulated radiation therapy (IMRT) for treatment of his adenocarcinoma of the rectum.  Findings:  Two physician reviewers found that according to the most recent National Comprehensive Cancer Network (NCCN) guidelines, IMRT should only be used in the context of a clinical trial. Preoperative radiation therapy per the German Rectal Cancer group study established this pre-operative chemoradiation as the standard of care, and it was associated with a low rate of gastrointestinal grade 3-4 toxicity (Sauer, et al). On this study, the authors noted that conventional radiotherapy (3D conformal) was utilized to deliver the radiation treatment. In this case, there is nothing specific about the patients clinical presentation which would require the utilization of IMRT over standard techniques. Despite the tumor being concave and irregular, which is the case for the majority of rectal cancers, 3D conformal radiotherapy techniques would result in an acceptable and low level of risk for developing radiation related toxicities. In addition, the small dosimetric benefit provided by an IMRT plan is not likely to result in a clinically significant benefit. For these reasons, the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Experimental/Investigational
Decision: Upheld

ture of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for postural restoration services. The possible etiologies of diaphragmatic paralysis include trauma and iatrogenic interventions. Absent clear trauma or iatrogenic etiologies, cases are deemed to be due to an idiopathic neuropathy. Treatment can include surgery such as diaphragmatic plication and implantation of diaphragmatic pacemakers. Limited studies have also suggested a possible role for phrenic nerve reconstruction for treatment of diaphragmatic paralysis. Overall, there is a lack of data demonstrating improved patient health outcomes, including pulmonary function, with the use of postural restoration services for diaphragmatic paralysis. All told, the requested postural restoration services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Findings:  Three of the three physician reviewers found the requested postural restoration services are 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 requested services are 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 physical medicine and rehabilitation with subspecialty certification in pain management and is actively practicing. Physician reviewer 2 is board certified in physical medicine and rehabilitation and is actively practicing. Physician reviewer 3 is board certified in physical medicine and rehabilitation 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: Medical Necessity
Decision: Upheld

A 56-year-old female enrollee has requested a folding power wheelchair for treatment of her cerebral vascular accident (CVA) with left-sided hemiparesis.  Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the requested folding power wheelchair. Based upon the documentation provided, the patient has a mild hemiparesis and is functionally independent with a single point cane and a walker for longer distance mobility. In addition, a power chair is indicated for individuals who require a primary means of ambulation and not a means of community transportation. The record indicates that the patients activity goal is to use a power chair for community mobility. Given that the patient is able to ambulate with a cane and walker, the requested equipment is not medically necessary in this clinical setting.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for pulsed radiofrequency nerve ablation (destruction of neurolytic agent, unlisted procedure, nervous system;  fluouroscopic guidance and localization of needle; and moderate sedation services).Findings:  Two out of three physician reviewers found that this patient reported a history of tailbone area pain since a fall in 2005. The medical literature on pulsed radiofrequency nerve ablation is limited. Most studies are retrospective and non-controlled. A 2018 study by Usmani and colleagues concluded that the requested services (pulsed radiofrequency) were inferior to conventional radiofrequency ablation. An evidence-based review by Chen and colleagues also found that patients who underwent conventional (vs pulsed radiofrequency treatment) and who received prognostic blocks were more likely to experience a positive outcome. Accordingly, pulsed radiofrequency nerve ablation (destruction of neurolytic agent; unlisted procedure, nervous system; fluouroscopic guidance and localization of needle; and  moderate sedation services) is not likely to be more beneficial than any other available standard treatments for this patients medical condition.Final Result: The reviewers determined that the requested services are not likely to be more beneficial than any other available standard treatments for this patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in physical medicine and rehabilitation 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

A 24-year-old male enrollee has requested rhinoplasty for treatment of his nasal deviation. Findings:  The physician reviewer found that according to the records provided for review, the patients condition of traumatic nasal fracture has resulted in at least a slight asymmetry of the nasal dorsum. This condition can therefore be considered an abnormal structure of the body since it is not the normal state of the patients nose. In addition, the abnormal structure of the body was caused by trauma. However, the preferred surgery will not offer more than minimal improvement in the appearance of the patient according to the description given by the provider. Rhinoplastic surgery for this patient would result in only minimal change in the appearance of his nose, and therefore the proposed surgery does not meet criteria for reconstructive surgery as set forth by California law.With regard to whether rhinoplasty is medically necessary for this patient, the submitted documentation does not include evidence of a functional impairment. The follow-up notes from the patients otorhinolaryngologist do not include any reports of significant pain, discomfort or impaired breathing. Nor does the submitted plastic surgery consultation document any functional issues. As such, the medical necessity of the proposed surgery has not been established.
Appeal type: Medical Necessity
Decision: Overturned

A 51-year-old male enrollee has requested Celebrex 200mg for treatment of his pain. Findings:  The physician reviewer found that the submitted clinical documentation demonstrates the medical necessity of the requested medication in this patients case.  Celebrex is in a class of medication which provides low risk for gastrointestinal ulcers, even in patients with a history of gastroesophageal reflux disease.  Celebrex is also considered safer in those with gastrointestinal sensitivity to nonsteroidal anti-inflammatory medication, for example in patients following gastric bypass surgery.  This patient has been diagnosed with gastrointestinal reflex disease and is status post gastric bypass surgery.  The current medical evidence supports the requested medication in this clinical setting.  All told, Celebrex 200mg is medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

A 63-year-old female enrollee has requested for deep tissue massage therapy for treatment of her abdominal adhesions.  Findings:  The physician reviewer found that the clinical data supporting this therapy are limited only to management of occluded fallopian tubes. Thus, there is inadequate justification for its use in this patients care and is therefore not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

A 43-year-old male enrollee has requested past and future coverage for inpatient residential care services provided, and re-admittance to residential level of care.  Findings:  The physician reviewer found that at the time of admittance to the residential treatment facility, this patient was actively depressed and alcohol dependent. The patient was undergoing numerous travails in his personal life and had access to a loaded weapon that he contemplated using to commit suicide a few days prior to admission. The patients relapse risk was thus intensified in potential outcome severity. He was unable to maintain sobriety as an outpatient and his living situation was not supportive of recovery. Although he did not require an inpatient level of care for withdrawal, he did require a safe structured inpatient setting to establish stability and safety before an outpatient program could be safely and effectively utilized. Thus, the services provided were medically necessary for treatment of the patients alcohol dependence. The patient was discharged from the treatment facility with after care instructions. No additional medical records have been provided since the patients discharge to support the current request for re-admittance to residential level of care. Therefore, future inpatient residential treatment services are not medically necessary at this time. However, the patient should receive an immediate psychiatric evaluation to determine the level of care that is appropriate.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for referral to a hematologist. Macrocytosis without anemia may be related to specific drugs, including metformin, excessive alcohol intake, non-alcoholic liver disease, or nutritional deficiencies, including vitamin B12 and folate. With regard to B12 deficiency, Pavlov and colleagues note that vitamin B12 deficiency most significantly affects functions of blood, nervous system and inflammatory response. In this case, the patient has a history of polyneuropathy and is taking vitamin B supplements, which appear to be helping. She also has type 2 diabetes, which may be contributing to her painful neuropathy. Laboratory testing demonstrated increased mean corpuscular volume (MCV) suggestive of mild macrocytosis. Additionally, this testing demonstrated normal B12 and folate levels. The patient is also on metformin, which is associated with macrocytosis. The noted macrocytosis was not noted on prior hemograms. Based on a mildly abnormal MCV on one hemogram without anemia, a referral to hematology is not medically indicated at this time. Therefore, the requested referral to a hematologist is not medically necessary for the evaluation of this patient. Final Result: The reviewer determined that the requested service 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 neurology 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 patient is a 38-year-old female with symptomatic breast hypertrophy examined by her chiropractor and referred to a board certified plastic surgeon for relief of the noted symptoms of mid and upper back pain. She was examined and photographed by the plastic surgeon. A request for prior authorization was made to her Health Plan. Authorization was granted for the breast reduction, which requested an estimated amount of tissue to be removed as well as the patients height and weight. The patient underwent the procedure but the amount of tissue that the Health Plan had stipulated to was not removed. The Health Plan has subsequently denied coverage for the procedure indicating that based on the amount of tissue that was removed the procedure was not medically necessary.Reviewed were the presented medical records, letters from the patients providers and the patient and photocopies of photographs of the patient. These records and photos document that the patient indeed had large pendulous breasts and had long-standing back pain secondary to the large breasts. The breast procedure carried out was a breast reduction of moderate volume.The patient underwent the procedure to relieve her documented symptoms. It was therefore medically appropriate and indicated. The patient indicates that her symptoms were relieved by the procedure. That a smaller amount of tissue than the authorized volume was removed does not negate the medical necessity of the procedure. As such, I have determined the procedure at issue was medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Overturned

The parent of a three-year-old female has requested a magnetoencephalograpy (MEG) and magnetic source imaging (MSI) for the evaluation of epilepsy.  Findings:  Two physician reviewers found that MEG and MSI is indicated in sorting out and mapping different types of functional cortex and can be helpful in determining viability of surgical resection of malignant brain tissue and epilepotenic tissue from surrounding normal functioning cortex. It is particularly helpful in establishing interictal epileptic spike activity and has demonstrated superiority compared to other invasive and noninvasive approaches and provides superior data compared to MRI, PET or SPECT scanning
Appeal type: Medical Necessity
Decision: Overturned

A 39-year-old male enrollee has requested neuropsychological testing for the date in question, for treatment of his metastatic gastroesophageal adenocarcinoma status post right paramedian cerebellum resection and radiosurgery. Findings: The physician reviewer found that upon reviewing the current medical literature, it becomes clear that whole brain radiation therapy (WBRT) is considered the standard of care for brain metastases. WBRT decreases the tumor burden, which delays neurocognitive decline and maintains quality of life. However, WBRT can also cause brain injury and neurologic complications. Specifically, there is risk of dementia in long-term survivors of brain metastases treated with WBRT, which is thought to be dependent on the total dose of radiation, the size of the irradiated field, and the fraction size. Understanding and measuring the neurotoxicity associated with WBRT is important for evaluating different treatment regimens beyond the effects on survival and time to disease progression. In addition, baseline neurocognitive function also is predictive of overall survival. In one publication from Li and colleagues, the researchers examined the short-term impact of WBRT on neurocognitive and quality of life measures. In the study, patients were administered neuropsychological tests at baseline, at the end of radiation therapy, and at one-month follow-up. Although declines in tests scores occurred immediately after radiation, improvements in neurocognitive and quality of life measures were found at one month post-WBRT compared to pre-WBRT, with the majority of patients showing improved or stable performance compared to baseline in memory, attention, and executive function. Further, most clinical trials employ neurocognitive assessments at the baseline as well as post radiation. Future clinical trials will be designed to answer questions such as the role of omitting upfront WBRT, the benefit of administering prophylactic cranial irradiation to highly metastatic cancers, the value of using hippocampal sparing techniques, and the addition of radiosensitizers. In order to answer these questions and evaluate various treatment regimens that may have minimal differential effects on survival and disease progression, it is important to assess other patient outcomes, especially functions affected by neurotoxicity. For these reasons, tests of neuropsychological functioning should be included as standard outcome measures in patients treated with WBRT. Thus, the diagnostic testing performed in this patients evaluation was therefore medically indicated and necessary for evaluation and treatment of this patients condition.
Appeal type: Experimental/Investigational
Decision: Overturned

A 46-year-old female enrollee has requested a laparoscopic sleeve gastrectomy for treatment of her hypertension and obesity.  Findings:  Three physician reviewers found that a consensus statement on LSG was issued and recently published by the American Society for Metabolic and Bariatric Surgery (ASMBS). This report compiles the most recently published studies and best available data and follow-up for the currently available surgical interventions for treatment of morbid obesity and moderate to severe co-morbid conditions. The LSG procedure is endorsed by the ASMBS as a primary procedure without the requirement of second stage. It has also been recommended as a primary procedure for those with inflammatory bowel disease, severe small bowel adhesions, and patients with the need to continue specific medications including non-steroidal anti-inflammatory drugs (NSAIDs), as is the case with this patient. For these reasons, the LSG procedure is likely to be superior for treatment of this patients obesity as compared to other standard treatment options. Therefore, I have determined the requested surgery is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned

A 44-year-old male requested authorization and coverage of surgical removal of sebaceous cysts.  The health plan denied the enrollees request indicating that the requested procedure is not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer overturned the health plans denial on the basis that the requested procedure is medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 10-year-old male enrollee requested individual speech therapy at the frequency of one hour per week for medical treatment of the enrollees expressive language disorder.  Findings:  The physician reviewer found that the submitted documentation establishes the medical necessity of the requested therapy. Based upon the documentation provided, the patient has a serious speech problem. His speech is intelligible 70% of the time to people who know him and per the Goldman-Fristoe Test of articulation he scored in the lowest percentile for age. The patients speech impairment is likely impacting his learning as he cannot be readily understood by his teachers or his peers. Moreover, a home program as recommended by the Health Plan is not appropriate in this case, given his degree of speech impairment. Therefore, based on the medical literature cited above and documentation submitted for review the medical necessity of the requested individual speech therapy at the frequency of one hour per week has been established in this clinical setting.
Appeal type: Medical Necessity
Decision: Overturned

A 28-year-old female enrollee has requested Lamisil for treatment of her onychomycosis.  Findings:  The physician reviewer found that the patients medical condition, onychomycosis, would be most effectively treated with oral Lamisil. The relative efficacy and safety profiles of this drug, compared to other systemic antifungal drugs, justify the choice of continuous terbinafine therapy in this case. Onychomycosis is a common nail ailment associated with significant physical and psychological morbidity. Various treatment modalities including topical, systemic and surgical have been used for onychomycosis. Topical drugs are delivered through specialized transungual drug delivery systems ensuring high concentration and prolonged contact. Commonly used oral therapeutic agents include Lamisil, fluconazole, and itraconazole. Terbinafine and itraconazole are given as continuous as well as intermittent regimes. Continuous terbinafine appears to be the most effective regime for dermatophyte onychomycosis (Gupta and Cooper). Lamisil is a synthetic antifungal in the allylamine class and has fungicidal activity against dermatophytes, molds, and certain dimorphic fungi, as well as fungistatic activity against Candida albicans. Following oral administration, Lamisil is absorbed rapidly and reaches peak plasma concentration within two hours. Lamisil has been proven to be standard therapy of onychomycosis as it is very effective, well tolerated, and has a relatively low potential for drug interactions. Consistent with these findings, the requested medication is supported as medically necessary for treatment of this patients medical condition.