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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for general anesthesia services. The Health Plan has denied this request indicating that the requested services are not medically necessary for management of the enrollees dental condition.  Findings: There is sufficient support in the documentation provided for the requested anesthesia services in this clinical setting. Local anesthetics are the pharmacologic mainstay for pain control during oral surgery procedures. General anesthesia would need to be employed in order for the patient to tolerate the procedure.  Performance of the procedure under general anesthesia will result in improved safety for the patient and allow for a blunted autonomic response to stress and anxiety. For these reasons, general anesthesia services is medically necessary for the management of this patients medical condition.Final Result: The reviewer determined that that the requested services are 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 oral and maxillofacial surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested digital breast tomosynthesis for the evaluation of the enrollee, who was asymptomatic.  Findings: Two physician reviewers found that the Health Plan has denied the request for reimbursement for the digital breast tomosynthesis.  Per the Health Plan, the service at issue was investigational for the evaluation of this patient. According to Skaane and colleagues, the use of mammography plus tomosynthesis in a screening environment resulted in a significantly higher cancer detection rate and enabled the detection of more invasive cancers. Ciatto and colleagues noted that integrated two dimensional and three dimensional mammography improves breast cancer detection and has the potential to reduce false positive recalls. Thus, the medical literature supports the use of digital breast tomosynthesis over conventional mammogram due to improved cancer detection rate. In sum, digital breast tomosynthesis was likely to have been more effective than other methods of evaluating this patient.Final Result: Two reviewers determined that the service at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: All three physician reviewers are board certified in diagnostic radiology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 5-year-old male enrollee has requested inpatient psychiatric hospitalization for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found that the inpatient psychiatric hospitalization provided from the date indicated forward was and is medically necessary for treatment of the patients medical condition. This is the patients fourth inpatient hospitalization in just over two months. There was only a 10-day period between his third and fourth admission. These facts evidence that the patient has very quickly relapsed absent the 24-hour structure of the program and requires a longer inpatient stay in order to prevent future relapse. In addition, the notes from the date indicated show that the patient was completely uncooperative with the simplest of activities, having vital signs taken. Thus, if the patient is unable cooperate with this activity, he would likely be unable to function in a less restrictive environment. The physician and parents both are concerned that the patient is not ready or able to attend school. In that regard, the physician has instituted a program of exposure therapy to gradually increase his tolerance so he will be able to function in a less restrictive environment without relapsing within a few days, which has previously happened. As such, the medical necessity of the disputed treatment has been established.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested Prolia injections bimonthly for treatment of her osteoporosis and pancreatic cancer.  The physician reviewer found that Prolia is approved by the U.S. Food and Drug Administration (FDA) and is indicated for treatment of women with postmenopausal osteoporosis who are at high risk of fracture.  The Xgeva label also states that it is indicated for prevention of skeletal events in patients with solid tumor bony metastases. This patient has no evidence of bone metastases from her pancreatic cancer. There is however evidence for osteoporosis based on her T-score of -2.61, which confers a high risk of fracture. This level of osteopenia meets the standard cut-off at which point pharmacologic therapy is indicated. Thus, the use of Prolia in this patient is consistent with the FDA label and with standards of care for osteoporosis. In addition, Prolias prescribing information for dosage and administration states administer 60 mg every six months as a subcutaneous injection. Thus, Prolia every two months is not indicated. In sum, the Prolia injections every six months were and are medically necessary. Final Result: The reviewer determined that a portion of the services at issue were and are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned.  Credentials/Qualifications: The reviewer is board certified in 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: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Synvisc One injections for treatment of her osteoarthritis.   The physician reviewer found that there is sufficient support for the services at issue in this clinical setting.  In their meta-analysis of 137 studies with 33,243 participants, Bannuru and colleagues concluded that hyaluronic acid was the best pharmacologic intervention for knee osteoarthritis. Hyaluronic acid was found to be better than injected placebo or injected corticosteroids.  Pagnano and Westrich conducted a systematic review on the efficacy and safety of repeat courses of hyaluronan therapy in patients with osteoarthritis of the knee and concluded that repeat courses of the hyaluronans were safe and effective in the treatment of pain associated with osteoarthritis of the knee.  The peer-reviewed literature supports the use of repeat series of viscosupplementation injections for the treatment of pain in patients with osteoarthritis of the knee.  In this case, the patient has undergone prior Synvisc One injections with significant benefit documented in terms of both pain reduction and maintenance of function in activities of daily living. Therefore, Synvisc One injections were medically indicated for the treatment of this patient. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications:   The reviewer is board certified in 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: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested an overnight hospital stay and hospital care for treatment of his medical condition. Findings:  The physician reviewer found that the overnight hospital stay was not medically necessary in this clinical setting. Inpatient care is necessary when the patients signs and symptoms and general medical condition can only be managed safely in an acute inpatient setting, when the patient requires diagnostic studies in an inpatient setting, or if it is medically necessary for the patient to remain in the acute inpatient setting. Outpatient observation admission is appropriate when the physician is unsure about the patients need for inpatient admission and requires time for short-term treatment, assessment, and reassessment in order to make that decision or the physician anticipates that the patients condition can be evaluated/treated within 24 hours and/or rapid improvement of the patients condition can be anticipated within 24 hours. In this case, the patient had symptoms of palpitations, at the time of admission his symptoms had improved and he was in stable condition. In this case the patient was admitted in stable condition and could have been treated at an observational level of care. As such, the hospital care received was medically necessary; however, the overnight hospital stay was not medically necessary. 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 partially overturned.  Credentials/Qualifications: The reviewer is board certified in internal 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 authorization and coverage for continued speech therapy and continued occupational therapy. The medical records provided for review do not document that this patient has an impairment in articulation of speech or oral motor function aspects of speech which would warrant coverage of speech therapy services. The patient endorses that her ultimate goal has to been to freely communicate her thoughts, concerns, needs and wants across social and emotional dynamics. However, these communication goals are considered social in nature. In addition, many adults with autism spectrum disorder prefer talk therapy. Moreover, the patient does not have any documented deficits that require treatment with formal occupational therapy. All told, the requested continued speech therapy and continued occupational therapy are not medically necessary for treatment of this 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 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

The parent of a 15-year-old male enrollee has requested for continued Nutropin growth hormone therapy for treatment of the enrollees stated short stature/growth failure. Findings:  The physician reviewer found that the recorded height nears 54. Growth hormone deficiency and celiac disease has been excluded. The mid-parental height was above the 25th percentile. The projected adult height at 13 years 4 months was below the 3rd percentile, and he had a subnormal rate of growth. He was placed on growth hormone therapy and has had an excellent response. The patients excellent growth response indicates the benefits of continuing growth hormone therapy.
Appeal type: Medical Necessity
Decision: Overturned

A 19-year-old male enrollee has requested inpatient psychiatric hospitalization level of care for treatment of his psychosis. Findings:  The physician reviewer found that on the date indicated, the patient had a reassuring presentation.  Per nursing, he was still isolative, but receptive to guidance.  He was engaging the therapeutic milieu, sleeping and eating well, and appropriately maintaining his activities of daily living.  The physician mental status examination reported no suicidal ideation, homicidality, recent aggressive behavior or hallucinations.  There had been no recent or proposed changes to the antipsychotic medication regimen.  Thus, transition to a less restrictive setting would have been appropriate on the date indicated.  All told, inpatient psychiatric hospitalization level of care from the time frame specified was medically indicated.  Per the medical records, the medical necessity of inpatient psychiatric hospitalization level of care from the subsequent time frame has not been established.
Appeal type: Medical Necessity
Decision: Upheld

A 45-year-old female enrollee has requested authorization and coverage for Pradaxa 150mg for treatment of post cerebrovascular accident.  Findings:  The physician reviewer found that Dabigatran (Pradaxa) is a new oral direct thrombin inhibitor.  In a study by Connolly and colleagues, dabigatran clinical use was evaluated in a large, open-label, randomized trial in which it was compared to warfarin in patients with non-valvular atrial fibrillation who had at least one additional risk factor for stroke.  In this trial, dabigatran was associated with lower rates of stroke and systemic embolism, although there were similar rates of major hemorrhage.  Of note, there appeared to be an increase in the risk of myocardial infarction (not statistically significant) in patients receiving dabigatran, and there was a significant increase in dyspepsia as compared to patients receiving warfarin. Pradaxa is medically indicated for the prevention of stroke and systemic embolism in patients with non-valvular atrial fibrillation.  This patient had a stroke and was diagnosed with meningioma three years later.  In a review of the records provided, the etiology of her stroke is not indicated.  The submitted documentation does not indicate a history of atrial fibrillation.  Additionally, the documentation does not indicate evidence of an embolic etiology for her stroke. Therefore, the clinical rationale for long-term anticoagulation therapy is not demonstrated from the records provided for review.  The use of this agent for the treatment of this patient is not consistent with contemporary evidence-based clinical practice.  All told, Pradaxa 150mg is not medically indicated in this patients case.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested intensive outpatient program (IOP) services for treatment of her behavioral health condition.  Findings:  The physician reviewer found that in this clinical setting, the treatment services provided to the patient were medically necessary. Per the records, her substance abuse was dominating daily functionality. Considering the presentation, an intensive outpatient (IOP) program was reasonably expected to improve the patients condition and prevent a more serious episode of illness. The level of care was safe, appropriate and consistent with accepted medical practice while the duration of care was consistent with community standards.  Finally, the American Psychiatric Publishing Textbook of Substance Abuse Treatment documents that patients who participate in IOP programs show improved functionality and decreased mortality is associated with individuals who complete the program. In sum, the services at issue were medically necessary for treatment of the patients behavioral health condition. Final Result: The reviewer determined that the services at issue were medically necessary for treatment of the patients behavioral health condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: The 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: Urgent Care
Decision: Overturned

The parent of a 16-year-old male enrollee has requested reimbursement for emergency services. Findings:  The physician reviewer found that the patient is a 16-year-old male, who presented to the emergency room on the date in question with sore throat and poor oral intake for several days. However, he had no documented fever.  The physical examination noted the patient to have an elevated heart rate of 120 with normal blood pressure and no fever.  Throat examination noted swollen tonsils with exudate.  He was treated for strep throat and discharged to home. The patients parent has requested reimbursement for the emergency services provided. At issue in this case is whether a prudent layperson in the patients circumstances would have sought immediate medical attention on the date in question. California law defines an emergency medical condition as a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in any of the following: (1) Placing the patients health in serious jeopardy; (2) Serious impairment to bodily functions; (3) Serious dysfunction of any bodily organ or part.This patient presented with a sore throat. However, in this case he also had a significant elevation in his heart rate, which is consistent with a more serious condition. Frequently an increased heart rate can be related to fever, but he was afebrile.  In this case the patients elevated heart rate was likely from dehydration, which often is treated with intravenous fluids.  Even if the patients parent could have been in contact with the patients primary care provider and had reported an elevated heart rate, the patients provider likely would have sent the patient to the emergency department for evaluation. Therefore, a prudent layperson experiencing these symptoms would have sought emergency medical attention.
Appeal type: Medical Necessity
Decision: Overturned

A 42-year-old female requested authorization and coverage for gastric bypass surgery.  The health plan has denied this request indicating that the requested procedure is not medically necessary for treatment of the enrollees obesity.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 depending upon the results of a psychological evaluation.
Appeal type: Experimental/Investigational
Decision: Overturned

An enrollee has requested authorization and coverage for wireless capsule endoscopy. This patient has symptoms consistent with possible Crohns disease. Upper endoscopy and colonoscopy with biopsies have been performed, but most of the small bowel has not been evaluated. Capsule endoscopy is useful for the diagnosis of Crohns disease or determination of the extent of disease activity, and is superior to radiographic imaging tests such as small bowel follows through. Capsule endoscopy has proven to have a superior yield of data compared to all current forms of radiological testing of the small intestine. For these reasons, the requested wireless capsule endoscopy is likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: The reviewers determined that the requested services are likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewers 1, 2, and 3 are board certified in internal medicine with subspecialty certification in gastroenterology 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has reimbursement and prospective authorization and coverage for percutaneous tibial nerve stimulation treatments for treatment of the enrollee who has a history of neurogenic bladder and urinary incontinence. Findings: The physician reviewer found that there is a lack of support in the literature for the superior efficacy of the services at issue. In most cases of overactive bladder, behavioral treatment is considered as first line therapy. Antimuscarinic drugs alone or in combination with intermittent self -catheterization, are currently the mainstay of conservative treatment. Several other medications may help in specific disease conditions. Second line treatment includes botulinum toxin A injection and indwelling catheters. Third line of therapy for selected patients include neuromodulation and surgery. Percutaneous tibial nerve stimulation may also be indicated when standard conservative therapies have been tried and failed. In this patients case, the records do not reflect that she has been treated with first and second line therapies. Therefore, percutaneous tibial nerve stimulation treatments were not and are not likely to be of greater benefit than the standard therapies for the treatment of this patients medical condition. Final Result: The reviewers determined that the services at issue were not and 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: All three physician reviewers are board certified in urology 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.