Persius/imr-appeals huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Overturned

The submitted information indicates the patient is 34-year-old woman who has keratoconus. The clinical notes indicate she is having problems tolerating a contact lens. She is status post penetrating keratoplasty in the other eye. The patients ophthalmologist has recommended the patient undergo a penetrating keratoplasty. The Health Plan indicates scientific evidence does not support the requested procedure as safe and effective for treatment of the patients condition.Keratoconus in one of the primary indications for penetrating keratoplasty, particularly when the patient is contact lens intolerant or has such a high degree of irregular astigmatism that a contact lens cannot adequately improve the vision. Penetrating keratoplasty is not an experimental procedure. It is well documented in the literature as effective and there have been excellent results in keratoconus patients. Therefore, I have determined that the requested procedure is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Butrans patch. Findings:  The physician reviewer found that the physician reviewer found the submitted documentation supports the medical necessity of the requested medication. The patient has Crohns disease. The use of chronic opiate agonists in Crohns disease may cause narcotic bowel syndrome, resulting in a worsening of the pain. The use of opiates in Crohns patients has also been associated with an increased risk of infections. Because of these two issues, chronic oral opiate therapy is controversial. However, Butrans patch has not been shown to have these issues at this time. All told, the requested Butrans patch 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 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: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested 3D breast tomosynthesis for evaluation of her breast cancer screening. Findings:  Three physician reviewers found that breast tomosynthesis is a technique that was developed several years ago as a problem solving adjunct to routine mammography. Applying the same basic concept as computed tomography (CT) scanning, the logic is that by separating the various layers of breast tissue, one can better detect abnormalities. This has been shown to be most useful in the evaluation of dense breasts. Therefore, in this clinical setting, the tomosynthesis was likely to be more beneficial than breast sonography as a screening tool alone.    Final Result: Three 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 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: Experimental/Investigational
Decision: Upheld

A 62-year-old male enrollee has requested a kyphoplasty for treatment of his compression fractures. Findings:  Three physician reviewers found that Kyphoplasty remains an unproven technique for the management of vertebral compression fractures. Among individuals age 50-80 years, 5-20% have one or more vertebral crush fractures. One-third of these patients require treatment for acute or chronic pain. Vertebroplasty and kyphoplasty were introduced over the last two decades as treatments for incapacitating pain from osteoporotic vertebral fractures. The use of kyphoplasty for traumatic thoracic fractures remains an unproven procedure without established clinical efficacy. Additionally, patients should exhaust all non-operative measures prior to considering surgical intervention.
Appeal type: Urgent Care
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for services for treatment of an emergency medical condition.  Findings:  The physician reviewer found that The services provided  were necessary for treatment of an emergency medical condition. Evidence-based medical guidelines recommend prompt consultation with hand surgeons for patients presented with possible finger extensor tendon rupture, and support initial radiographs and imaging for a significant change in symptoms and/or findings suggestive of significant pathology. The peer-reviewed literature indicate that EPL tendon ruptures are associated with screw head protrusion after the use of volar locking plates for distal radius fractures and support follow-up with hand surgeons for such events. In this case, the patient sustained severe multiple traumatic injuries in a motor vehicle accident and was status post open reduction and internal fixation of a right distal radius and ulnar styloid fracture. He experienced an acute loss of right thumb function while attending college. He presented to an out-of-state urgent care center for evaluation. Clinical exam documented a loss of tendon function and the patient was referred to an orthopedic surgeon for evaluation. The orthopedic surgeons opinion was that the EPL tendon had ruptured and ordered an MRI for confirmation. Surgical repair of the tendon was performed at a later date. Given the abrupt loss of thumb function and complex surgical history, the services at issue were necessary for treatment of an emergency medical condition. Final Result: The reviewer determined that the patient received emergency medical services on the dates of service at issue. 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

A 25-year-old female enrollee has requested eating disorder partial hospitalization program services for treatment of her  eating disorder, not otherwise specified.  Findings:  The physician reviewer found that this patient presented with chronic underlying issues of significance including insecurity, self-defeating behaviors, mood symptoms and anxiety, along with a distorted self-image and unhealthy food cravings.  Such a confluence of symptoms necessitates ongoing comprehensive specialty care.  However, based on the patients progress and stability, continued partial hospitalization program services were no longer medically necessary by the indicated date.  In sum, partial hospitalization services were medically necessary but not thereafter.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for radiofrequency ablation services. Based on the patients physical presentation and history, the requested radiofrequency ablation is not likely to provide this patient with an improved health outcome when compared with standard therapies. In the medical literature, radiofrequency ablation may provide long-term results in well selected patients. However, the current studies have included fibroids measuring 6-7 cm in maximum size. Given the lack of long-term data of the radiofrequency ablation, uterine artery embolization or hysterectomy would likely be more effective treatment options for this patient than radiofrequency ablation. Thus, the requested radiofrequency ablation services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Findings:  Three physician reviewers found the requested radiofrequency ablation services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested radiofrequency ablation services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in obstetrics and gynecology 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential treatment center services for treatment of the enrollees behavioral health conditions. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the services at issue in this clinical setting. This patients drug use was central to his daily routine and contributed to his significant impairment across multiple domains of functionality. He had strained family relations.  He had depressive symptoms.  He had a history of medical problems secondary to his drug use, including methicillin-resistant staphylococcus aureus (MRSA) abscesses from intravenous drug use. Per the records, this patient had not consolidated the treatment gains necessary to succeed in the outpatient setting after less than a week of residential care. Two days prior to the timeframe in dispute, the patient had poor focus with difficulty articulating his thoughts, along with anxiety, depression and craving. Thereafter, according to the records provided, the patient was actively engaged in treatment during the admission, including the addition of mood stabilizing medications in his final week of the admission. The services and setting were safe, appropriate and consistent with good practice, while the duration of treatment aligned with community standards for a case of this severity and facilitated transition to a less restrictive setting. Additionally, the services provided at the time were reasonably expected to improve his condition and prevent a more serious episode of illness. 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 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:   An enrollee has requested a permanent subcutaneous defibrillator (S-ICD) for treatment of his medical condition.   Findings:  Two physician reviewers found that there is sufficient support for the requested services in this clinical setting.  In this patient's circumstance, an implantable defibrillator is reasonable and considered standard accepted practice in the medical community.  Placement of a subcutaneous defibrillator has potential long-term advantages in this patients case.  For this young patient who will likely require a defibrillator for many decades, the risk of lead failure and lead extraction, which are associated with significant morbidity and mortality, are higher when implanted with a traditional endocardial lead device.  Subcutaneous leads are not subject to the stresses of the cardiac contraction and so should be less likely to fail or need replacement.  Also, if lead failure were to occur then the subcutaneous lead should be easier to access and extract with lower risk of morbidity.  Furthermore, the patient's cardiac condition does not predispose to symptomatic bradycardia that may require backup pacing only provided by a standard endocardial defibrillator lead.  Therefore, given the long-term advantages of a subcutaneous defibrillator in this patient and the unlikely need for therapies provided only by an endocardial lead system, the requested permanent subcutaneous defibrillator is likely to be superior over other treatment options.   Final Result: Two reviewers determined that the requested services are likely to be more beneficial for treatment 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 internal medicine with sub-specialty certification in cardiovascular disease 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

A 47-year-old male enrollee has requested continued skilled nursing facility services, including physical therapy for treatment of his medical conditions. Findings:  The physician reviewer found that based on the clinical documentation submitted for review, the medical necessity of continued skilled nursing facility services, including physical therapy has not been established. In this case, the patient has a severe myopathy of unknown cause that has led to profound functional impairment. Physical therapy reportedly worsens his symptoms, thus additional physical therapy is not medically necessary. In addition, extensive exercise therapies are not part of treatment in this clinical setting. Stretching to reduce the risk of contracture is important; however this does not require skilled therapists. Therefore, the continuation of skilled nursing facility services, including physical therapy is not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for lidocaine 5% patch and magnetic resonance imaging (MRI) of the hip joints. The records provided for review document that this patient presents with a history of complex regional pain syndrome (CRPS), thoracic fractures with malunion, and post-traumatic thoracolumbar kyphosis with progressive low back and hip pain. In a letter, the provider noted that the patient has not experienced sufficient improvement, or been able to tolerate, treatment with Lidoderm. The records do not demonstrate that the patient is likely to respond well to lidocaine patches given her lack of response to treatment with Lidoderm. Moreover, there is a lack of support for the requested MRI of the hips. The patient has a history of chronic widespread pain attributed to chronic regional pain syndrome and thoracic malunion. However, there is no report that an MRI is indicated for further evaluation of her chronic medical conditions. All told, the requested lidocaine 5% patch and MRI of the hip joints are not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested medication and 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 orthopedic surgery with subspecialty certification in sports 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

Nature of Statutory Criteria/Case Summary: A 66-year-old male enrollee has requested authorization and coverage for surgery to fuse back bones (lumbar spinal fusionfor treatment of the enrollees lower back pain. Findings:  The physician reviewer found that The submitted documentation supports the requested services in this patients case. This patient presents with a one year history of progressively worsening low back pain and neurogenic claudication. Significant functional difficulty is documented in ambulation and standing tolerances. He is status post L4-S1 lumbar instrumented fusion in 2013. Evidence of long-term reasonable and/or comprehensive nonoperative treatment protocol trial and failure has been submitted. This patients symptoms are consistent with imaging evidence of moderate to severe central canal narrowing and severe bilateral lateral recess narrowing with potential impingement on the bilateral L4 nerve roots. There is imaging evidence supporting the need for wide decompression that would result in temporary intraoperative instability and necessitate fusion. Removal and replacement of the existing L4-S1 hardware would be supported with extension of the fusion to L3. The current medical evidence supports the requested services in this clinical setting. All told, the requested surgery to fuse back bones (lumbar spinal fusion) 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 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

A 43-year-old female enrollee requested authorization and coverage of a gastric bypass surgery consultation. The Health Plan denied this request indicating that the requested consultation is not medically necessary for evaluation of the enrollees morbid 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 consultation is medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld

A 52-year-old female has requested coverage for amniotic membrane placement for treatment of her visually significant pterygium.  Findings:  Three physician reviewers found that the patient underwent surgical excision with conjunctival autograft and prophylactic subconjunctival amniotic membrane placement.  The documentation noted no operative complications.  Pterygia must be surgically excised when vision is affected.  Primary excision without further intervention results in a moderately large rate of recurrence, and recurrences are frequently more aggressive than the original lesion.  Therefore, it is advantageous to find methods to reduce the recurrence rate.  The use of a conjunctival autograft or amniotic membrane placement over the defect has resulted in statistically significant reductions in the recurrence rate.  In this patients case, she received a conjunctival autograft and a prophylactic subconjunctival amniotic membrane around the conjunctival autograft.  At this time, clinical trials have not demonstrated the greater efficacy of the amniotic membrane placement in this setting.  Thus, the services at issue were not likely to have been more beneficial than other options for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested genetic testing (MyRisk) for evaluation of her medical condition.   Findings:  Two physician reviewers found that BRCA1 mutation can increase risk for breast, ovarian, cervical, uterine, pancreatic, gastric, and prostate cancers.  BRCA2 mutations can increase risk for breast, ovarian, gallbladder, bile duct, prostate, pancreatic, and gastric cancers.  In the event the BRCA tests were negative, there is still a possibility of hereditary predisposition from another gene defect.  There are guidelines in place that evaluate the occurrence of Lynch syndrome or hereditary nonpolyposis colorectal cancer (HNPCC) tumors in families.  The most common extracolonic cancer in Lynch syndrome is endometrial cancer followed, in no particular order, by ovarian, gastric, renal, small intestine, pancreas, hepatobiliary, and ureteral.  In this patients case, the MyRisk panel was appropriate since the current clinical situation may be caused by several potential cancer-causing genes.  In sum, genetic testing (MyRisk) was likely to have been superior over other options.   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 internal medicine with sub-specialty certification in medical oncology 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

The parent of a 17-year-old female enrollee has requested sub-acute residential psychiatric services for the treatment of the enrollees major depressive disorder, attention deficit disorder and generalized anxiety disorder. Findings:  The physician reviewer found that though the patient apparently suffers from some degree of ADHD and dysphoria, the degree was not so flagrant as to have warranted months of residential treatment. Her medication adjustments could easily have been accomplished on an outpatient basis. Similarly, while the group therapies appear to have been of some use, these could have taken place on an outpatient basis.