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

A 57-year-old female enrollee requested authorization and coverage of out-of-network provider care for the treatment of mastocytosis.  The Health Plan denied the enrollees request indicating that the requested treatment 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 services are  medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 25-year-old female has requested chiropractic services for treatment of her neck pain.  Findings:  The physician reviewer found that based upon the medical records provided, the requested chiropractic care is medically necessary for treatment of the patients neck pain. The patients symptoms, clinical exam findings and physical therapy notes demonstrate that she meets the criteria for chiropractic treatment, in accordance with the Cochrane Library and Mercy Guidelines for chiropractic treatment. The submitted records from the patients providers, document the following: muscle imbalance of the cervical spine and shoulder girdle, decreased functional mobility, and an altered physiological function of the spine. Chiropractors are neuromuscular specialists and have particular expertise in managing these issues. Additionally, it is not indicated by the American Chiropractic Association, Mercy Guidelines, or the Cochrane Medical Library that patients complete a course of physical therapy prior to undergoing chiropractic treatment. The Medicare Guidelines specify the PART criteria for chiropractic treatment. The PART guidelines stated that patient must demonstrate pain, asymmetry of the muscles, range of motion difficulties and temperature change/muscle spasm. The physical therapy evaluation documents that the patient meets all of the PART criteria. Based on the current accepted chiropractic guidelines and the patients medical records, the requested chiropractic services are medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

A 54-year-old female enrollee has requested an oxygen concentrator for treatment of her chronic obstructive pulmonary disease (COPD).  Findings:  The physician reviewer found that the patient had an overnight pulse oximetry to assess for nocturnal oxygen desaturation in 2010. At that time, the patients longest oxygen desaturation was 84%, and in 2011 it was 86%. Petty and Bliss reported on the Nocturnal Oxygen Therapy Trial (NOTT) study and concluded that use of an ambulatory oxygen system increased oxygenation of the arterial blood results. Based on the lowest drop in oxygen, the patient is a candidate for treatment with an oxygen concentrator for nocturnal use. However, a sleep study should be performed to first rule out obstructive sleep apnea. For these reasons, the requested equipment is not medically necessary at this time.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:   An enrollee has requested a sleep study for evaluation of her medical condition.  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  The purpose of a CPAP titration study is to determine the optimal setting of CPAP treatment for those patients who have met criteria for treatment with CPAP.  The diagnostic study in the patients record had a normal apnea-hypopnea index.  The usual criteria for treatment with CPAP include an apnea-hypopnea index of 15 or greater.  In this patients case, her apnea-hypopnea index was 3.8, which is normal.  For patients with heart disease or hypertension, the criteria for CPAP include an apnea-hypopnea index of 5 or greater.  This patient did not meet standard criteria for the medical necessity for CPAP.  Therefore, a sleep study was not medically indicated for the treatment of this patient.   Final Result: The reviewer determined that the services at issue were not medically necessary for evaluation 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 disease 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 53-year-old female enrollee has requested for a dual energy x-ray absorptiometry (DEXA) bone density scan for evaluation of her risk for osteoporosis.  Findings:  The physician reviewer found that the American Association of Clinical Endocrinologists (AACE) state in their osteoporosis guidelines that BMD measurements should be performed for risk assessment in peri-menopausal or post-menopausal women who have risk factors for fractures and are willing to consider available interventions. The AACE further comments that testing is appropriate for establishing skeletal stability and monitoring therapeutic response in women receiving treatment for osteoporosis. To this end, obtaining baseline measurements prior to intervention in all women 40 years and older who have sustained a fracture is recommended.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential treatment. Findings:  The physician reviewer found that modern psychiatric practice aims to place patients in the least restrictive treatment setting.  In general, community intervention settings optimize treatment gains.  However, episodic placement in more restrictive settings is often clinically appropriate for those with serious addiction and comorbid mental illness.  In this case, the patient had a serious addiction to alcohol which contributed to interpersonal discord, occupational problems, depression, and health issues.  He had a co-occurring psychiatric disorder treated with a pro-serotonergic medication, escitalopram and then mirtazapine, in addition to quetiapine and gabapentin.  He had a complex medical history of hypercoagulability and thyroid disease, and concerning physical sequelae from his drinking, including a history of electrolyte imbalance, seizures, and delirium tremens.  The patient was unable to maintain sobriety in his environment.  Per the records, the patient had not consolidated the treatment gains necessary to succeed in the outpatient setting after just three weeks of care.  Further, he did not have a strong sober support network.  The patient was attending, participating and benefitting from the residential programming, which included family involvement, psychiatric services, individual therapy, group therapy, sponsorship and an array of chemical dependency non-pharmacologic interventions.  The treatment was appropriate and reasonably expected to further the patients improvement while minimizing the chance of relapse.  Further, the duration of treatment was well within community practice standards and facilitated a seamless transition to the next residential treatment setting.  All told, residential treatment provided was medically necessary for the treatment of this patient. Final Result: The reviewer determined that the services at issue were medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The physician reviewer is board certified in psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested Actemra 162 mg/0.9 syringe (tocilizumab) for treatment of the enrollees medical condition. Findings: The physician reviewer found that the medical literature supports the use of tocilizumab in this clinical setting. Tocilizumab is a monoclonal antibody that binds the IL-6 receptor blocking its activation from IL-6 cytokine. This medication is U.S. Food and Drug Administration (FDA) approved for treatment of inflammatory arthritis such as rheumatoid arthritis (RA) and systemic juvenile idiopathic arthritis. The FDA label states that tocilizumab is indicated in RA when the patients disease has progressed while on other medications. In this case, the patient has contraindications to steroids and other medications since they would interfere with her immunotherapy. Nevertheless, this patient needs therapy for acute bouts with arthritis.  Therefore, treatment for this patients medical condition with tocilizumab is medically necessary.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 medical oncology and hematology 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

A 29-year-old male enrollee requested lactulose free nutritional supplement PediaSure for treatment of the enrollees chronic developmental delay.  Findings:  The physician reviewer found that the records indicate this patient with cerebral palsy is underweight and treated with PediaSure. However, the patients weight appears to be stable and there is no evidence that the patient cannot tolerate a pureed diet. In addition, there is no evidence of a nutritional or specialist consultation. The documentation does not demonstrate that the patient has tried a pureed diet and failed. Therefore, the continued use of PediaSure 5-10 cans per day is not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 65-year-old female enrollee has requested water exercise with a physical therapist for treatment of her knee pain. Findings:  The physician reviewer found that the rehabilitative management of patients following total joint arthroplasty should be individualized and geared toward the specific functional needs of a given patient.  A recent randomized controlled trial by Rahmann and colleagues has demonstrated the beneficial effects of aquatic physiotherapy following total joint arthroplasty. In this patients case, there is a significant pain component that could limit functional recovery.  It is therefore likely that the patient will better tolerate and progress with an aquatics-based program as opposed to a land-based therapeutic exercise program. The requested services are medically appropriate and likely to result in an improved outcome for this patient as compared to land-based therapy.
Appeal type: Urgent Care
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested emergency services on an emergent 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 mild abdominal pain with dysuria and hematuria. The patient denied fevers, vomiting, or other systemic symptoms. Her vital signs were normal and she was not in acute distress. Based on the patients presenting complaints and symptoms, a prudent layperson in this circumstance would not reasonably believe she 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 requested 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 mild abdominal pain with dysuria and hematuria. The patient denied fevers, vomiting, or other systemic symptoms. She related her symptoms were consistent with prior urinary tract infections. A patient with a history of urinary tract infection would likely have known that immediate medical attention was not 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 58-year-old male enrollee has requested Roux-en-Y gastric bypass surgery for the treatment of his excess weight and related conditions. Findings:  The physician reviewer found that this patient meets nationally accepted criteria for authorization of bariatric surgery. This patient has severe morbid obesity with serious comorbid conditions including diabetes and hypertension. The 2004 Bariatric Surgery Consensus Conference statement supports prompt bariatric surgery in this circumstance.  There is documentation that full reversal of diabetes is severely diminished when surgery is delayed.  Further, surgery will improve the patients life expectancy.  Additionally, and quite significantly, non-operative approaches have nearly 100% failure rate in class III obese patients, such as this patient.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: an enrollee has requested authorization and coverage for Repatha SureClick subcutaneous 140 ng/mL injection every two weeks. Findings:  The physician reviewer found that that this patient cannot tolerate high potency statins, she would not be able to use a high potency statin in conjunction with Repatha, which is contraindicated. Stress testing may not detect non-occlusive coronary artery disease (CAD) and may be falsely negative in the setting of balanced ischemia. The records document that the patient had a trial of Praulent, which is another PCSK9 inhibitor, that demonstrated efficacy reducing her LDL to less than 70 mg/dL, further supporting the future use of Repatha given her inability to tolerate statin therapy. 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 cardiovascular disease 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

This patient is a 28-year-old woman who has irritable bowel syndrome (IBS) with constipation dominance. The patient has been taking Zelnorm for several months. The submitted documentation indicates that since the patient has been taking Zelnorm she has had normal bowel habits and no abdominal pain. The Food and Drug Administration (FDA) approved dosage for Zelnorm is 6mg twice daily for four to six weeks, which could be extended another four to six weeks depending upon results. The patient wishes to continue treatment with Zelnorm. The Health Plan has denied authorization for Zelnorm on the basis that it is not medically indicated.Although the duration of the patients use of Zelnorm has exceeded FDA guidelines, IBS and constipation are lifelong conditions. The patients provider has indicated that the patient has not responded to any conventional medications. In addition, it has been noted that the patient has developed rectal prolapse due to her severe constipation. In this particular case, given the patients clinical condition and her past success with Zelnorm, continued use of Zelnorm may be medically indicated. However, this determination cannot be made because the information submitted does not contain the necessary recent history to determine whether the patient is experiencing any of the known complications from the medicine such as syncope, diarrhea, or symptoms of ischemic colitis. Absent a sufficiently detailed history, the prolonged use of Zelnorm is contraindicated. Therefore, I have determined that the requested medication is not medically necessary for treatment of the patients medical condition at this time. The Health Plans denial should be upheld at this time. However, if the patients provider submits documentation demonstrating the patient has no history consistent with known complications to Zelnorm, the Health Plans denial should be reconsidered because the patient has demonstrated a positive response to Zelnorm and no other medication previously tried was beneficial.
Appeal type: Medical Necessity
Decision: Upheld

A 46-year-old female enrollee has requested subcutaneous immune globulin (Vivaglobin) for treatment of her common variable immune deficiency (CVID) and persistent methicillin-resistant staphylococcus aureus (MRSA). Findings:  The physician reviewer found that there are two main methods for delivery in CVID treatment which are intravenous immunoglobulin (IVIG) and subcutaneous immunoglobulin (SCIg). In a study by Chapel and colleagues comparing IVIG against SCIg, the authors concluded that there were no significant differences in outcomes in terms of safety or efficacy between the two methods of delivery. Although some providers may contend there are fewer systemic reactions with SCIg, these contentions have not yet been established. Thus, without any substantial benefits seen in the scientific data and no specific indication for the requested therapy over the standard alternative, there is no clinical justification for the use of IVIG instead of SCIg for this patients condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for phototherapy.Multiple studies have demonstrated favorable results supporting the use of phototherapy for the treatment of lichen planus. Phototherapy has been a well-accepted therapy for this condition. Iraji and colleagues conducted an unblinded, randomized trial of patients with generalized lichen planus and found a significantly better response in the patients who received phototherapy as compared with low dose prednisone. Complete responses were attained by 52 percent of patients in the phototherapy group versus 13 percent of patients in the steroid group. In this case, the patient presented with an itchy rash all over her body. Records show that her condition worsened, which prompted a biopsy of the rash. The biopsy confirmed that the patient had lichen planus. She was started on clobetasol propionate cream, which has been ineffective in treating her condition. The current medical evidence supports phototherapy in this clinical setting. Therefore, phototherapy is medically necessary for the treatment of the patients medical condition.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 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 a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested speech therapy for treatment of the enrollees speech delay. Findings: The physician reviewer found that the review of the submitted documentation and medical literature demonstrates the medical necessity of the requested therapy. Speech development is an important predictor for later problems, such issues with reading and spelling, among other learning difficulties. Law and colleagues examined the effectiveness of speech and language interventions for children with primary speech and language delay/disorder. The authors found that overall there is a positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulties. In this case, the patient has significant expressive speech delay and language impairments. As such, speech therapy has been established as medically necessary in this clinical setting.Final Result: The reviewer determined that the requested therapy 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 pediatrics and neurology with special qualification in child 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the bilateral breast tomosynthesis performed for evaluation of the enrollees breast cancer examination. Findings:  Two physician reviewers found that the patient presented with an area of palpable concern in one of his breasts. Once a palpable mass is noted, it is imperative to identify and characterize the mass or to be reasonably confident that a biopsy is not necessary. While male breast carcinoma is unusual, it does occasionally occur, and it is not unreasonable to perform tomosynthesis in this clinical setting. The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor. Final Result: The reviewers determined that the services at issue were 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: Reviewers 1, 2, and 3 are board certified in diagnostic radiology 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.