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

Nature of Statutory Criteria/Case Summary:   An enrollee has requested Harvoni for treatment of his hepatitis C. Findings:  The physician reviewer found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America, all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions.  This applies regardless of fibrosis stage or viral load.  Per the guidelines, genotype 1 patients who have failed peg-interferon and ribavirin should be treated with Harvoni for 12 weeks. These guideline recommendations are based on multiple randomized clinical trials, and the medication is U.S. Food and Drug Administration (FDA) approved for all patients with chronic hepatitis C, genotype 1 regardless of fibrosis stage.  The requested treatment with Harvoni is medically necessary 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 internal medicine with sub-specialty certification in gastroenterology  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

The parent of a 17-year-old male enrollee has requested blood tests, comprehensive stool analysis tests and urine porphyrins tests for evaluation of the enrollees medical condition. Findings:  The physician reviewer found that the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested testing. In this case, the patient is asymptomatic with quiescent asthma. According to the medical records, the patient does not present with symptoms of bloating, cramping, gas or bulky stools. In addition, the patient had a screening evaluation performed for a malabsorption condition and both laboratory work and a physical examination showed no clinically significant findings. As such, the requested testing is not medically necessary for evaluation of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for magnetic resonance imaging (MRI) of the knee for evaluation of the enrollees knee pain.  Findings:  The physician reviewer found that the MRI of the knee performed was medically necessary for evaluation of the patients medical condition. MRI is the optimal means to evaluate an internal derangement. Plain x-rays are of limited value given that the menisci and ligaments are not visible on plain x-rays. The American College of Radiology (ACR) appropriateness criteria for acute trauma to the knee recommend MRI of knee for trauma due to a fall or twisting injury with either no fracture or a Segond fracture seen on a radiograph or suspected internal derangement. This scenario applies to this patient. For patients who have sustained recent trauma and have physical signs and symptoms suggestive of an internal derangement, an MRI is the most appropriate and relevant diagnostic imaging procedure. In the clinical setting of acute trauma with suspected internal derangement such as a ligament tear, and where surgery is likely, an MRI is clinically indicated and delaying the MRI is not medically reasonable. Final Result: The reviewer determined that the diagnostic procedure at issue was 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: Urgent Care
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for services at a hospital while the patient stayed in Thailand. At issue is whether the services provided at the hospital in Thailand were urgent services, defined as services to prevent serious deterioration of the patients health resulting from an unforeseen illness or injury for which treatment cannot be delayed until the patient returns to the plans service area.The American College of Rheumatology (ACR) recommendation for the management of hip osteoarthritis includes nonpharmacologic modalities such as exercise, weight loss for overweight patients, psychosocial interventions, physical therapy, and walking aids, as well as pharmacologic modalities such as medication management and intraarticular hyaluronate injections, duloxetine, and opioids for patients with inadequate response to initial therapy. The authors recommend total joint arthroplasty for patients with hip osteoarthritis following failed medical therapy. In this case, the patient had a diagnosis of right hip osteoarthritis and presented for total right hip replacement following five months of progressively worsening pain. While initially approved, the surgery was delayed due to scheduling issues and for the resolution of a urinary tract infection. The documentation did not reflect that the patients procedure was emergent or urgent, or that recommended conservative treatment to manage the symptoms had been trialed. Therefore, the services provided at the hospital in Thailand were not urgent services, defined as services to prevent serious deterioration of the patients health resulting from an unforeseen illness or injury for which treatment cannot be delayed until the patient returns to the plans service area.Final Result: The reviewer determined that the services at issue were not urgent services, defined as services to prevent serious deterioration of the patients health resulting from an unforeseen illness or injury. Therefore, the Health Plans denial should be upheld.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: Upheld

The patient is a 16-year-old female with a longstanding history of depression, anorexia, suicidal threats, running away, alcohol and amphetamine use, and promiscuity. She was admitted to a residential treatment facility in December 2004 and resided there through August 2005.  She then ran away to California with a male friend she met along the way and was eventually found by her brother at the home of a friend. After being hospitalized for three days in a California psychiatric facility, she returned to the residential treatment facility. The residential treatment staff noted that she was feeling dead inside and numb upon her return.  These feelings, in conjunction with her depression and underweight condition, led to her referral for inpatient psychiatric treatment.Her inpatient psychiatric treatment focused on preventing her from binging and purging and active treatment for her depression with Zoloft 100mg and Abilify 7.5mg twice per day. She was not actively suicidal at any time during her acute inpatient stay and was reported to have gained some weight. Clinical notations indicate her sadness had decreased somewhat, though her mood still fluctuated from happy to sad.  Her parents are now requesting reimbursement for the acute inpatient psychiatric services.  The Heath Plan denied the request based upon a determination that the services at issue were not medically necessary.Prior to her acute inpatient psychiatric admission, the patient was already in a residential treatment facility. The purpose of residential treatment is to treat longstanding psychiatric illnesses and it is not clear from the record why the patient required transfer to another psychiatric facility. The charter of residential treatment programs is to provide active, ongoing, psychiatric treatment. The patient was not actively suicidal and her difficulties, inclusive of self-destructiveness, were chronic, not acute in nature. As such, she ought to have continued her treatment in the residential facility. There was no indication for acute inpatient psychiatric care and I have determined the services at issue were not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

A 43-year-old male enrollee has requested coverage for weekly outpatient psychotherapy from a specific date and forward for treatment of his bipolar disorder.  Findings:  The physician reviewer found that Roman and Gillig concluded that a combination of psychotherapy and pharmacotherapy is superior to pharmacotherapy alone for patients with frequent relapses of Bipolar Disorder. Miklowitz also noted that adjunctive psychotherapy enhances the outcomes of Bipolar Disorder. The records indicate the patient is safe to be treated on an outpatient basis, treatment goals are clear, frequency and duration are appropriate for severity of illness and he cannot be managed at a lower level of care. The patients symptoms suggest a co-occurrence of both depressive and hypomanic symptoms. Psychotherapy has been shown to help reduce this patients symptoms, but like any other treatment, it does need to be continued for maintenance. In addition, the general standard for maintenance psychotherapy is weekly, not every other week. All told, weekly psychotherapy is appropriate to treat the patients condition, consistent with good medical practice, and is therefore medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

A 51-year-old female enrollee has requested for a dermatology consultation for treatment of her hemangioma. Findings:  The physician reviewer found that there is no supporting documentation in the patients medical record indicating that the patients primary care physician has requested the assistance of specialty dermatology services in this patients case.  Additionally, there is a lack of documentation of a medical need for treatment or removal in this patients case, including pain, itching, chronic bleeding, or changing size.  All told, the requested dermatology consultation is not medically indicated in this patients case.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a two-year-old female enrollee has requested speech therapy at a frequency of two one-hour sessions per week for treatment of the enrollees speech delay.  Findings:  The physician reviewer found that extensive review of the literature, including meta-analysis by Law and colleagues, noted a positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulty. Feldman and Messick  also note that treatment for language disorders is predicated primarily on the childs language profile and level of communication skills. Intervention in the form of speech therapy attempts to create an optimal language learning environment which capitalizes of the importance of environmental stimulation in the process of learning language. Children who participate in speech-language treatment show better improvement than children who have no treatment. Approximately half of children delayed at two-years of age  catch up to peers by three-years of age. Children with mild to moderate disorders are more likely to resolve their delay compared to those with severe disorders. Appropriate receptive language skills and symbolic play are associated with resolution of delays.  In this patients case, the requested speech therapy at a frequency of two one-hour sessions per week is medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

A 45-year-old female has requested coverage for magnetic resonance imaging (MRI) of the breasts for evaluation of her risk for developing breast cancer.  Findings:  The physician reviewer found that currently there is evolving evidence of the utility of breast cancer screening using MRI in certain subgroups of patients. The consensus is that MRI has a role in screening patients with a calculated lifetime risk of developing breast cancer of greater than 20-25%. While this particular patient does have a first degree relative who was diagnosed with breast cancer, the American College of Radiology (ACR) practice guidelines indicate that a strong family history usually refers to at least 2 first degree relatives or a known BRCA1 or BRCA2 genetic mutation. This patient has a negative physical examination and there is no mammography report in the records provided for review. There is mention of a mammogram which did not describe any abnormal findings. Thus, in the absence of extremely dense mammographic breast tissue, equivocal physical findings, or equivocal findings on standard imaging, the requested MRI of the breasts is not considered medically necessary. The standard first-line diagnostic procedure for screening is mammography, unless the breast tissue is characterized as extremely dense on mammography, which is a factor that may limit the utility of the technique. Such issues are not brought forward in this patients clinical picture and therefore the requested MRI of the breasts is not medically necessary.
Appeal type: Urgent Care
Decision: Overturned

A 30-year-old female enrollee has requested reimbursement for emergency services for treatment of the enrollees miscarriage.  Findings:  The physician reviewer found that the patient is a 30-year-old female who initially presented to an Emergency Department with complaints of vaginal bleeding. She was 6.5 weeks pregnant at the time, and apparently was found to have a threatened abortion, which indicated that she was bleeding, but the pregnancy was still felt to be viable. She next presented to her gynecologist at nine weeks pregnant by dates, but the fetus was 8.5 weeks pregnant by ultrasound without a heartbeat. At that time, she was thus diagnosed as having a missed abortion (miscarriage) and her provider advised her to have a dilatation and curettage (D&C) reportedly to reduce the risk of infection or bleeding. She underwent a D&C completion of her miscarriage the following day. At issue in this case is whether a prudent layperson in the enrollees 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.The patients symptoms on the date in question met prudent layperson criteria for emergency care. A prudent layperson in the patients circumstances would reasonably expect the absence of emergency care to jeopardize their health. In this case, this patient was diagnosed with a threatened abortion and was followed expectantly. The missed abortion was diagnosed at a later date. The InterQual criteria require an ultrasound confirmation of fetal demise for a D&C to be medically necessary. The patients clinical record documents such an ultrasound finding. The American College of Obstetricians and Gynecologists (ACOG) information for patients notes that a D&C may be done to prevent infection or heavy bleeding. Her provider counseled the patient that she could develop heavy bleeding or infection if she did not undergo a D&C completion of the miscarriage. Considering the instructions given the patient by her provider, the patient would have reasonably believed that she was experiencing an emergent medical condition when the services were provided on the date in question.
Appeal type: Medical Necessity
Decision: Upheld

A 25-year-old female requested authorization and coverage of the medication Remicade for the treatment of Crohn's 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 medication is not medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested breast tomosynthesis for evaluation of her medical condition.  Findings:  Two physician reviewers found that due to the advantages tomosynthesis brings radiologists in the interpretation of mammograms, by separating dense glandular elements from architectural distortion/mass, the American College of Radiology (ACR) suggested removing the technique from the investigational list. The tomographic quality of the tomosynthesis has proven to be particularly valuable in cases of very dense or heterogeneously dense tissue.  Overall, the addition of tomosynthesis to the usual two-dimensional (2D) imaging has resulted in a decrease in callbacks and increase in detection of small cancers.  Despite the lack of long-term studies showing an increase in survival rates when tomosynthesis has been used in screening mammography, the technique has gained worldwide support among radiologists and was likely of more benefit to the patient than had the exam been done with 2D imaging only. Final Result: Two 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:  All three reviewers are board certified in diagnostic radiology and are actively practicing. All three 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

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Fentanyl for treatment of her medical condition. Findings:  The physician reviewer found that the patient presented with a history of chronic pain. The step wise WHO ladder for pain relief is considered the reasonable approach to pain control in the palliative setting. (Raffa et al). In this patients case it does not appear all non-opioid treatment options had been utilized. Further, there was no plan in place to monitor this patients medications either historically and currently (Jamison et al). Moreover, it is unclear as to whether the diagnosis of chronic regional pain syndrome (CRPS) was supported. Based upon the information provided, the patient only appears to have met one of the criteria for such diagnosis and as noted in the medical records the patient has chronic pain syndrome and possibly fibromyalgia (Wurtman). Finally, multiple minimal requirements for opioid prescribing were not documented and the need to use Fentanyl to taper the patients opioid use is not supported. Pain specialists generally use taper medications that are not long-acting (which Fentanyl is). Rather than using Fentanyl, buprenorphine oral form or methadone would be used for tapering purposes to get off another opioid. Moreover, there is no need to actually change opioids to taper; the physician can simply start decreasing the already prescribed opioids. As such, the medical necessity of  Fentanyl has not been established.  Final Result: The reviewer determined that the medication at issue was 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 anesthesiology with sub-specialty certification in pain 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested magnetic resonance spectroscopy for evaluation of his medical condition.  Three physician reviewers found that in this patients case, the superior efficacy of the services at issue has not been established.  The records indicate that the patient has a history of adenocarcinoma of the prostate.  He was evaluated with magnetic resonance spectroscopy.  There is a lack of support for the services at issue in this clinical setting.  The utility and accuracy of prostate magnetic resonance spectroscopy for the diagnosis and monitoring of prostate cancer has not been demonstrated.  Therefore, magnetic resonance spectroscopy was not likely to be of greater benefit than other method of evaluating this patient.  Final Result: Three reviewers determined that the services at issue were 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:  One reviewer is board certified in diagnostic radiology and is actively practicing.  Two reviewers are board certified in urology and are actively practicing. All three 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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a consultation with an orthopedic surgeon for evaluation of the enrollees low back pain. Findings:  The physician reviewer found that in the medical literature, Tosteson and colleagues compared the effectiveness of surgery over non-operative treatment for four years in patients with similar conditions. The authors found that comparative effectiveness evidence for clearly defined diagnostic groups from Spine Patient Outcomes Research Trial shows good value for surgery compared with non-operative care over four years. Baranowska and colleagues reported on 601 patients with degenerative disc disease who underwent surgery, of whom 107 patients had previously undergone surgery. The authors noted that most frequent reasons for revision surgery of the same motor segment were recurrent disc herniation, inadequate decompression and inappropriate surgical technique. This patient has evidence of failed back surgery with low back and radicular leg pain. An orthopedic referral is medically necessary to evaluate her persisting pain and to manage it appropriately. As such, the request for an orthopedic referral is medically necessary for evaluation and management of the patients medical condition.  Final Result: The reviewer determined that the requested referral 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 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.