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

Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting authorization and coverage for DME, power seat elevator. The enrollee has paralysis, weakness and pain. She is unable to transfer, stand or walk. She cannot stand from a seated position, and she cannot shift her weight to manage pain and pressure relief. The enrollee cannot use a manual wheelchair due to pain, paralysis and poor grip. Her current power chair is broken. It is over five years old. The enrollees provider is requesting authorization for a seat elevator for the enrollees custom power wheelchair. Based on the diagnoses and the enrollees disabilities, the request for the power seat elevator is medically necessary. Literature shows the enrollees illness causes progressive weakness and and sensory loss; usually affecting the feet and legs at the beginning. It eventually affects the hands. Devices designed to improve mobility will improve the enrollees quality of life.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 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 61-year-old male enrollee has requested magnetic resonance imaging (MRI) (lower extremity) for evaluation of his knee pain.  Findings:  The physician reviewer found that based on review of the available records, it is appropriate for this patient to have an MRI of the left knee with findings on physical examination including knee pain, popping, medial, lateral and anterior pain, and lack of knee extension. The presence of medial compartment or lateral compartment degenerative osteoarthritis also needs to be assessed. Physical examination revealed tenderness, limited range of motion and pain. Given the loss of knee extension and mechanical signs of popping, the differential diagnosis should include degenerative osteoarthritis with osteochondral loose body versus degenerative or traumatic type tear of the medial meniscus or lateral meniscus, as well as ligamentous injuries. Although x-ray and MRI can provide the basis for anatomical imaging, MRI should enable a more precise diagnosis. Thus, the MRI and clinical findings will become the basis for this patients treatment. Consistent with these findings, the requested MRI of the lower extremity is supported as medically necessary for evaluation of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for air and associated ground ambulance transportation services provided for treatment of the enrollees medical condition status post-traumatic spinal cord injury. Findings:  The physician reviewer found that the air and associated ground ambulance transportation services provided were medically necessary for treatment of the patients medical condition. There is sufficient support in the peer-reviewed literature to support the services at issue in this clinical setting. Colleagues found an association between time to rehabilitation after a spinal cord injury (SCI) and lower functional level, concluding that Earlier rehabilitation following traumatic SCI may improve patients functional status at discharge. In this case, the patient sustained a cervical spinal cord injury with impairment of function. Timely rehabilitation can minimize health risks and improve functional outcomes. To receive early specialized rehabilitation air and ground ambulance were medically necessary. As such, the request for air and associated ground ambulance transportation services provided were medically necessary for treatment of the 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 physical medicine and rehabilitation with sub-specialty certification in neuromuscular 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: Experimental/Investigational
Decision: Upheld

A thirty-seven year-old female in the 29th week of pregnancy with antiphospholipid antibody syndrome is requesting reimbursement and prospective authorization for IVIG therapy.Reviewers Findings:The three reviewing physicians found that IVIG therapy has been proposed as a treatment for recurrent miscarriage due to immunologic causes. By the standard of care, recurrent miscarriage is defined as the occurrence of two or more miscarriages. The patient in this instance does not have a diagnosis of recurrent miscarriage. The reviewing physicians found that the Health Plan denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for the gene test, molecular pathology (mopath) procedure level 7 (CPT code 81406) for evaluation of her malignant neoplasm of pleura.  Findings:  Two physician reviewers found that There are no therapeutic implications for the diagnosis of CADASIL. This patient has diabetes, which is considered a vascular risk factor, and her MRI findings are consistent with vascular changes associated with her specific risk profile. In the absence of a family history of CADASIL and specific MRI changes in the temporal lobes there is a low clinical suspicion of CADASIL. In addition, the yield under these circumstances for CADASIL is not considered to be effective. Final Result: The reviewers determined that the requested testing is not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Reviewers 1, 2, and 3 are board certified in internal medicine and neurology 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 47-year-old female enrollee requested authorization and coverage of a laparoscopic vertical gastrectomy with a duodenal switch for the treatment of hypertension, chronic anemia, degenerative joint disease and G.I reflux disease.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 upheld the health plans denial on the basis that the requested procedure is not medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 45-year-old female enrollee has requested Botox injections for the treatment of her condition. Findings:  Two physician reviewers found that Botox therapy is helpful for torticollis, but it is not generally used for muscle spasms/myofascial type pain. The patient did have a 50% decrease in symptoms with Botox therapy, although it is unclear exactly where Botox was given. The patient has not tried migraine specific medications. The physician did start Topamax, but the patients response is not documented. The patient has many options for medication trials prior to considering Botox therapy.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for bilateral mastectomy for treatment of his gender dysphoria. Findings: The physician reviewer found that the documentation provided supports the requested procedure in this clinical setting. Each patient must be reviewed on a case-by-case basis to determine medical necessity. This patient has gender identity disorder and is transitioning to a male. He has evidence of abnormal breasts for a male despite the use of hormonal therapy. This medical condition would not likely resolve with continued hormonal therapy. While the Health  In this patients case, his breasts appear to be consistent with a teenage female. Hormone therapy will unlikely resolve this patients breast enlargement.  Since the condition will not resolve even with hormone therapy, surgical intervention to treat this patients dysphoria is medically reasonable and appropriate.  All told, this patient has evidence of abnormal breasts for a male and his medical condition will not likely improve with continued hormonal therapy. Therefore, bilateral mastectomy is medically necessary for the treatment of this patients gender dysphoria. With regard to whether the requested procedure is considered reconstructive in nature, the submitted documentation reveals that the patients breasts constitute an abnormal structure of a male body. Reconstructive surgery is performed on abnormal structures of the body, caused by congenital defects, developmental abnormalities, trauma, infection, tumors or disease. It is generally performed to improve function, but may also be performed to approximate a normal appearance. The patients breasts should be more consistent with male breasts. Based on the patients gender dysphoria and identification as a male, a normal appearance of the breasts for a male is the ultimate goal. In this patients case, he has evidence of abnormal breasts for a male. The goal of the surgery is to create a more normal appearing male chest and offer a more than minimal improvement in the appearance of the patient. All told, in this patients case, bilateral mastectomy is reconstructive in nature.  Final Result: The reviewer determined that the requested procedure is medically necessary and is reconstructive in nature for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in plastic 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

A 39-year-old male enrollee has requested a continuous passive motion (CPM) machine for the treatment of his medical condition status post anterior cruciate ligament replacement surgery. Findings:  The physician reviewer found that although the use of a CPM machine following arthroscopic surgery for ACL repair is not entirely uncommon, there is little support in the medical literature to support its use and further study is needed to prove its efficacy (Smith and Davies). Richmond and colleagues found that the prolonged use of CPM did not offer any additional benefit while Wright and colleagues stated that although a possible decrease in pain was noted in some studies, no substantial advantage was identified to justify the use of the device. Additionally, Engstrom and colleagues found no increased motion with use of CPM post-operatively.
Appeal type: Urgent Care
Decision: Upheld

A 25-year-old male enrollee has requested emergency services for the treatment of his medical condition. Findings:  The physician reviewer found that the prudent layperson standard for a medical emergency was not met in this case. The patient had been experiencing symptoms for 2-3 days and did not seek immediate care. Nor were his symptoms of such an acute nature as to cause a prudent layperson with an average knowledge of medicine to reasonably expect the absence of emergency care would jeopardize his health.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested V-Go Disposable Insulin Patch Pump for treatment of the enrollees medical condition.  Findings: The physician reviewer found that there is sufficient support for the requested equipment in this patients case.  Diabetic patients with drug use disorder show a higher rate of adverse health outcomes.  These patients experience more frequent and severe health complications, including an increased risk of hospitalization, readmissions and require longer hospital stays.  The prevention and management of substance abuse must be integrated with medical care.  This patient requires insulin for her diabetes.  However, she is not taking her insulin because the insulin syringes are a reminder of her intravenous drug addiction, and she is concerned that the syringes may be a trigger for resumption of drug use.  The V-Go system is an insulin delivery device that is effective and bypasses the need to utilize insulin syringes.  In order to provide the patient with the best treatment, which is insulin, the V-Go system is medically necessary.  The current medical evidence supports the requested equipment in this clinical setting.  All told, the V-Go Disposable Insulin Patch Pump is medically indicated for the treatment of this patient.Final Result: The reviewer determined that the requested equipment is 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 internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism 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 patient has requested authorization and coverage for Nerlynx (neratinib) tablets. There are several effective antibodies for the treatment of patients with HER2 positive breast cancer. Researchers concluded that Nerlynx plus capecitabine is active against refractory, HER2-positive breast cancer brain metastases. The U.S. Food and Drug Administration (FDA) initially approved Nerlynx for extended anti-HER2 adjuvant therapy. In February 2020, the FDA expanded this approval to include for metastatic breast cancer, when used along with Xeloda, as is being recommended in this patient. Moreover, this patients records document treatment and progression, or intolerance to, lapatinib, tamoxifen, and radiation therapy as well as Herceptin. Given the support in the medical literature and FDA approval, the requested medication regimen including Nerlynx with Xeloda is appropriate for treatment of this patients breast cancer with brain metastasis. Therefore, the requested Nerlynx (neratinib) tablets are medically necessary for 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 subspecialty certification in medical oncology 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 54-year-old female enrollee requested authorization and coverage of a CT scan to check for the presence of lung disease.  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: Upheld

A nineteen year-old male who has cocaine and marijuana dependence with a comorbid diagnosis of bipolar disorder is requesting authorization for continued psychiatric residential treatment services.  The patient has had multiple hospitalizations followed by entry into a dual diagnosis residential program. Reviewers Findings:The reviewing physician found that the submitted medical record reveal that the patient no longer meets medical necessity criteria for residential treatment.  Therefore, the reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

A 73-year-old male enrollee has requested Botox injections for treatment of his right foot dystonia. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested services in this patients case.  The current medical evidence supports Botox injections in this clinical setting.  The medical records noted parkinsonism with focal foot dystonia.  The medical literature has shown that Botox injections have a significant benefit in adult focal spasticity.  Botox injections have been shown to be safe and effective for the management of focal dystonia and spasticity in the lower extremities.  All told, the requested Botox injections are medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

A 40-year-old male enrollee has requested for radiofrequency lesioning (ablation) for treatment of his pain. Findings:  Three physician reviewers found that the current medical literature is not conclusive regarding the efficacy of radiofrequency ablation for this patients condition. There are few studies available and they only involve small numbers of patient at this time. A 2008 study by Cohen, et al. found that while the results of a placebo-controlled study provided preliminary support for the use of radiofrequency ablation, larger, multi-center studies with long-term follow-up and comprehensive outcome measures are needed to confirm our findings, further establish safety, and determine how best to identify candidates for this treatment. All told, there is a lack of evidence supporting the superior efficacy of radiofrequency ablation over alternative treatment options in this patient population.
Appeal type: Medical Necessity
Decision: Upheld

A 21-year-old female enrollee has requested residential treatment for the treatment of her behavioral health problems. Findings:  The physician reviewer found that the residential treatment services at issue were not medically necessary based on the following: there were no detoxification risks or co-occurring medical issues that required monitoring as the patient was detoxified during previously authorized days; there were no medical issues requiring monitoring as manifested by the absence of any post admission medical assessments, an absence of documented nursing monitoring and an absence of documented psychiatric monitoring; the patient was without any suicidal or dangerous ideation on admission and throughout this stay. She demonstrated no safety issues that required 24-hour monitoring or supervision. Furthermore, based on the available documentation, the patient did not meet American Society of Addiction Medicine (ASAM) criteria for a residential level of care. Under ASAM criteria, the patient was not noted to be intoxicated or to have any detoxification risks documented subsequent to the period she was in the sub-acute detoxification services. The patient was noted to have no major bio-medical issues that would complicate treatment. While she did undergo medical detoxification initially (during an authorized period of treatment), available documentation indicates she was seen only one time by a physician during this residential stay which falls well below the frequency of medical visits anticipated in a residential level of care. Thus, based on the established ASAM criteria, this patient did not require a residential level of care during the period at issue and could have been appropriately treated at a less intensive level of care.
Appeal type: Medical Necessity
Decision: Upheld

A fifty-eight year-old female who was diagnosed with breast cancer is requesting authorization for a PET scan.Reviewers Findings:  The reviewing physician found that without more information, the clinical indication for the PET scan cannot be ascertained.  The reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

A 21-year-old female enrollee has requested acute inpatient hospital services and sub-acute residential services for the treatment of her bulimia nervosa. Findings:  The physician reviewer found that this patient presented as a seriously impaired young woman with a complex group of psychiatric issues who was clearly in need of a comprehensive treatment plan at the time of acute admission. However, her specific need for inpatient treatment from the date in question forward and for residential treatment from the date in question forward has not been established. The patients body weight was stable and in the normal range. She was not psychotic, homicidal or suicidal. She appeared to be, at most, only moderately depressed. Although carefully observed by nursing personnel during her initial hospital days, she was able to go out of the hospital with her mother in a relatively short time. Her need for 24/7 professional monitoring and care is not substantiated by the submitted documentation. All told, the patient could have been safely and effectively treated at less intensive levels of care during the dates in question.