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

A 45-year-old female enrollee has requested Norco for treatment of her chronic pain.  Findings:  The physician reviewer found that the medical documentation fails to demonstrate the medical necessity of the requested medication in this patients case.  This patient has non-malignant chronic pain syndrome, which will often worsen or recur as a result of opioid rebound.  The current standard of care for chronic pain is treatment in a multidisciplinary practice to include physical therapy, massage therapy, cognitive behavioral therapy, and injections to help reduce pain.  The current medical evidence does not support Norco in the clinical setting.  Baron and McDonald reported that chronic use of high-dose opiates may contribute to pain sensitization via opioid-induced hyperalgesia.  Chronic opiates may also cause adverse outcomes, as noted by Ballantyne and Mao.  All told, Norco is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

The parents of a fifteen year-old male with short stature are requesting authorization of Increlex because of a putative diagnosis of IGF-1 deficiency. Reviewers Findings:The reviewing physician found that the patient had IGF-1 deficiency and thus should be allowed to continue treatment with Increlex long enough to show an adequate (or inadequate) growth response.  The physician concluded that the Health Plan denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for mental health services, more frequently (weekly or bi-weekly) for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services in this patients cases.  In a letter from a treating provider, the notation indicates that the patient is receiving and utilizing CBT and supportive therapy while continuing to assess the patients need for increased sessions. The provider noted that this current plan was discussed with the patients parent. The medical necessity of increasing the sessions to weekly or bi-weekly is not demonstrated by the submitted records.  Instead, the treating provider is suggesting less intervention for treatment of this patient. The provider does not recommend increasing the number of sessions at this time but will assess as needed. There is no clinical evidence to indicate that this patient is not benefitting from her therapy visits at the current rate. As such, the requested mental health services, more frequently (weekly or bi-weekly), are not medically necessary for treatment of this patient.  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 psychiatry with sub-specialty certification in child and adolescent psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:   An enrollee has requested surgery to remove an ovarian cyst for treatment of her medical condition.   The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  This patient has had a stable presumed ovarian cyst for many years.  It is unilocular, and she has a low CA-125, making the likelihood of ovarian cancer very low.  She has some pain, but has other potential etiologies for abdominal pain including adhesions and chronic narcotic analgesic use, which can cause bowel motility disorders and chronic pain.  This patient is very high risk to undergo surgery, as the records document obesity, asthma and known extensive abdominal adhesions.  Given the stability of the cyst, the benign nature of the ultrasound findings, and the co-existing medical problems that make her very high risk for surgery, the requested surgery to remove an ovarian cyst is not medically indicated for the treatment of this patient. 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 obstetrics and gynecology 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 representatives of a 55-year-old male enrollee requested authorization and coverage for continued skilled nursing facility (SNF) care.  The health plan has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees traumatic brain injury.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer overturned the health plans denial on the basis that the requested services are medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld

A 37-year-old female enrollee has requested artificial intervertebral disc replacement for treatment of her lumbar pain.  Findings:  Three physician reviewers found that the proposed artificial lumbar disc replacement is an experimental procedure without established safety and efficacy. There is no Class I long-term data demonstrating an advantage to disc replacement over fusion. The long-term safety profile is unknown and complications may be severe.
Appeal type: Medical Necessity
Decision: Overturned

A 47-year-old female enrollee requested an abdominoplasty and a panniculectomy for medical treatment of her abdominal pannus. Findings:  The physician reviewer found that the requested abdominoplasty is not medically necessary for treatment of the patients medical condition. It is not a medically necessary procedure unless the excess skin is required to close an open wound rather than being removed for cosmetic reasons.  The requested panniculectomy is medically necessary for treatment of the patients medical condition. The history of pannus skin infection and the photographic evidence of a chronic skin condition related to a large hanging pannus support the medical necessity of a panniculectomy in this patient.  Therefore, a portion of the requested services are medically necessary and reconstructive in nature for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested positron emission tomography (PET) with concurrently acquired computed tomography (CT) for attenuation correction and anatomical localization imaging, skull base to mid-thigh for evaluation of her left eye lesion. Findings:  The physician reviewer found that the medical literature noted that whole body PET/CT imaging has a high rate of detection of a primary tumor in patients with a carcinoma of unknown origin. The medical literature reported that PET with CT attenuation can demonstrate primary neoplasms and the whole-body total burden of disease. The medical literature found that carcinoma of breast is the most common primary malignancy that accounts for choroidal metastasis in females. Thus, the literature suggests that most intraocular masses are metastases, especially from lung and breast and these lesions have been successfully evaluated with PET/CT. All told, the requested PET with concurrently acquired CT for attenuation correction and anatomical localization imaging, skull base to mid-thigh is supported as medically necessary for evaluation of this patients medical condition. Final Result: The reviewer determined that the requested diagnostic procedure is medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: The reviewer is board certified in diagnostic radiology 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 61-year-old male enrollee requested computed tomography (CT) scan of the abdomen and pelvis (CPT code 74178 for medical evaluation of his medical condition.  Findings:  The physician reviewer found that the clinical notes document multiple episodes of gross hematuria, and the presence of gross hematuria is a well-recognized indication for CT of the abdomen and pelvis.  This examination searches for potential etiology of unexplained hematuria, including tumors, stones, and benign masses arising in the urinary tract.  All told, the CT scan of the abdomen and pelvis was medically indicated for the evaluation of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a replacement CPAP machine and accessories. The current medical evidence does not support the requested equipment in this clinical setting. The records document that the patient had an AHI of 2.1. Based on the home sleep study, he does not meet the criteria for obstructive sleep apnea. In order to establish the diagnosis of obstructive sleep apnea, AHI should be greater than 5. Based on the patients home sleep study in 2019, obstructive sleep apnea is not documented. A new sleep study showing an AHI greater than 5 will be required to support the medical necessity of a new CPAP machine. Therefore, the requested replacement CPAP machine and accessories are not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested equipment 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 internal medicine with sub-specialty certification in sleep 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 a consultation for possible surgery to remove two implant devices, which were reportedly placed in the enrollees left hand and groin/vaginal area. The Health Plan has denied this request indicating that the requested service is not medically necessary for treatment of the enrollees diabetes; peripheral neuropathy; chronic pain; hyperlipidemia; and coronary artery disease of the native artery. A review of the record indicates that the enrollee has been diagnosed with diabetes, peripheral neuropathy, chronic pain, hyperlipidemia, and coronary artery disease of the native artery. In a report dated, the provider noted the enrollee had persistent delusions that a chip had been implanted in her body. The provider reported no chip had been placed. The provider recommended treatment with psychiatry. The enrollees provider has not recommended consultation for possible surgery to remove two implant devices, which were reportedly placed in the enrollees left hand and groin/vaginal area.At issue in this case is whether the requested consultation for possible surgery; to remove two implant devices which were reportedly placed in the enrollees left hand and groin/vaginal area; is medically necessary for treatment of the enrollees medical condition. Colleagues noted that since no modality is perfect at identifying foreign bodies. A combination of high clinical suspicion a thorough physical examination and appropriate selection of the correct imaging modality will provide the best outcomes. In this case, the x-ray of the left forearm, showed a small nonspecific cyst, but no foreign bodies were identified. The physical examination, did not detect a mass in the left forearm or groin. The CT scan of the abdomen and pelvis did not note any foreign bodies. The radiographic studies and physical examination do not support findings of foreign bodies. Therefore, a surgical consultation for possible removal of foreign bodies is not medically necessary.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 general 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: The parent of an enrollee has requested authorization and coverage for air ambulance transportation. For infants born extremely prematurely and/or at very low birth weight, the medical evidence supports skin-to-skin contact. Contact with a parent, in particular the mother, promotes bonding and later breastfeeding, and enhances neurodevelopmental and physiologic organization. In this case, the mother went into preterm labor and delivered very early in the pregnancy. The baby had numerous complications as detailed above, requiring involvement of multiple sub-specialists. He continues to have complex medical needs, with an anticipated NICU stay. The current plan is to transfer him to a facility closer to home that can meet his needs while allowing active parent and family participation in his care, continued parent-infant bonding, and necessary family teaching. With transfer to the closest appropriate facility near the family home, this patient could have much needed contact with the parents and the rest of the immediate family, while continuing to receive the necessary level of care and sub-specialist involvement. This is consistent with current standard of care. Air ambulance is the appropriate form of transportation due to the patients condition and the distance. The literature supports active family involvement in the neurodevelopmental progress of neonates. The current standard of care includes active participation of both parents, maximizing interaction and skin-to-skin contact as frequently as the infants condition allows. Therefore, air ambulance transportation is medically necessary for the treatment of this patient. Final Result: The reviewer determined 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 pediatrics with sub-specialty certification in pediatric critical care 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 64-year-old female enrollee has requested a capsule endoscopy for the evaluation of anemia.  Findings:  The physician reviewer found that it is the standard of care to evaluate the small bowel in this setting. Capsule endoscopy is more sensitive than the standard small bowel series and can better identify minor lesions in the small bowel.
Appeal type: Medical Necessity
Decision: Overturned

An enrollee has requested authorization and coverage for the medication Xanax/Xanax XR. The submitted documentation reflects that the patient has panic disorder that is having a major impact on her quality of life and affecting her mood and anxiety. Records also reflect that the patient is in sustained, full remission from opioid use disorder. The medical literature does not support that Xanax is contraindicated for the treatment of panic disorder in patients who are in sustained, full remission from opioid use disorder. Under these circumstances, the requested medication Xanax/Xanax XR is medically necessary for treatment of the patients medical condition.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 psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A female enrollee requested Botox injections for medical treatment of her gastroparesis.  Findings:  The physician reviewer found that there is a lack of support for Botox injections in this clinical setting.  Bai and colleagues performed a systematic literature review evaluating the efficacy of Botox injection for patients with gastroparesis.  The authors concluded that there is no evidence to recommend this treatment for gastroparesis.  Camilleri and colleagues noted that intrapyloric Botox injection was not effective in randomized controlled trials.  In this patients case, there are multiple possible contributors to her gastrointestinal complaints.  The submitted records do not include contemporary documentation of gastroparesis or improvement of gastroparesis with Botox.  All told, Botox injections were not and are not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

A 36-year-old female enrollee has requested individual therapy for treatment of her depression, anxiety and suicidal ideation.  Findings:  The physician reviewer found that effective psychotherapy is a trusted intervention in the treatment armamentarium for patients with depressive and anxiety disorders. Current practice is focused on aggressive treatment of mental health conditions, particularly in the acute phase of the illness in which weekly sessions may be indicated, followed by less frequent services in the maintenance phase to foster patient autonomy and recovery. Applying the American Psychiatric Association (APA) guidelines, although this patient is functionally impaired, there is no evidence of imminent threat due to her chronic symptom burden. The medical records indicate that she has been attending weekly sessions with some improvement. Further, the patient was planned to be treated with electroconvulsive therapy, which remains the proven non-pharmacologic intervention in the treatment of mood disorders. Per the APA recommendation, treatment with electroconvulsive therapy should be adequate to determine a clinical outcome. In sum, individual psychotherapy is not supported as medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 16-year-old male enrollee has requested inpatient residential care for the treatment of the enrollees behavioral health problems. Findings:  The physician reviewer found that according to Child and Adolescent Level of Care Utilization System (CALOCUS) criteria, a rating of serious functional impairment alone (i.e., independent of other dimensions) requires care at a level of five which is residential care with 24-hour services with psychiatric monitoring. Serious functional impairment per CALOCUS is defined as a serious deterioration of interpersonal interactions with consistently conflicted or disrupted relations with others which may include impulsive or abusive behaviors. It also includes significant withdrawal and avoidance of almost all social interaction. The patient refused to attend school, no longer interacted with his peers, and refused to see a therapist. Thus, his symptoms were consistent with serious to severe functional impairment. Additionally, there was a highly stressful home environment due to conflict with his parents. Furthermore, the patient had a poor response to prior outpatient treatment with minimal engagement and acceptance of such treatment given his refusal to attend therapy. Therefore, inpatient residential care was indicated and medical necessary for this patients behavioral health problems. This finding is also consistent with the American Academy of Child and Adolescent Psychiatry practice guidelines.
Appeal type: Medical Necessity
Decision: Upheld

A forty-nine year-old female with stage T1, Nx, Mx rectal cancer and is status post colonoscopic removal is requesting an out-of-network formal proctectomy with reconstruction  low anterior resection.Reviewers Findings:  The reviewing physician found that it appears the patient has received authorization to have the proposed procedure performed by an in-network colon and rectal surgeon, the requested services performed out-of-network are not medically necessary.  The Health Plan denial was upheld.
Appeal type: Medical Necessity
Decision: Upheld

A 45-year-old male enrollee requested proton beam radiation therapy for medical treatment of his prostate cancer.  Findings:  The physician reviewer found that review of the submitted documentation fails to establish the medical necessity of the requested services. PBRT is not the standard of care for treatment of prostate cancer and it is not routinely offered to patients. The National Comprehensive Cancer Network (NCCN) guidelines for prostate cancer state Proton beams can be used as an alternative radiation source. Other treatment approaches such as IMRT are highly effective and well tolerated. There is a lack of compelling data that suggests that PBRT affords a benefit over standard approaches. In addition, there is data in the peer-reviewed literature that shows worse outcomes with PBRT therapy. According to a study by Sheets and colleagues, proton therapy has resulted in a greater risk of gastrointestinal toxicity versus intensity-modulated radiation therapy (IMRT.)