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

The patient has requested authorization and coverage for inpatient psychiatric care. The patients twice weekly outpatient psychotherapy abruptly stopped then she reported increased symptoms of depression, anxiety with vegetative signs of depression. This rapid decline occurred within days after reporting that she was doing ok and the provider noted the patient was stable. In treatment, the patient consistently reports passive, with occasionally active, suicidal ideation. There have been no reports of active suicidal plan or intent. This has become the patients baseline on review of all of the psychotherapy notes provided. Throughout treatment, the patients provider has noted that partial hospitalization program (PHP) level of care was available if necessary, and the patient has consistently declined it. The patient would be able to continue psychotherapy, which is a service that is provided in a PHP. There is no evidence that the patient poses an immediate danger to herself or to others. She has not demonstrated any self-harming behaviors, she was not gravely disabled, and she is cognitively intact. She has not been manic, psychotic, agitated or impulsive. She has not been abusing substances, and she has been compliant with all forms of treatment and medications. Overall, she does not require the structured setting of 24-hour nursing care and medical monitoring. PHP level of care, as recommended by the provider and approved by the Health Plan, is the appropriate setting. Thus, the requested inpatient psychiatric care is not medically necessary for treatment of this patients behavioral health issues. 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 subspecialty certification in geriatric 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 27-year-old male enrollee has requested air ambulance services for the treatment of his head trauma. Findings:  The physician reviewer found that the Health Plan does not agree that the air ambulance services the patient received were medically necessary. Specifically, the Health Plan states that air ambulance services are covered in exceptional circumstances. The patients condition must be such that immediate and rapid ambulance services could not have been provided by land ambulance or the time needed to transport the patient by land poses an immediate threat to his health. These circumstances could include the point of pick up not being accessible by ground ambulance, great distances, limited time frames, or other obstacles involved in getting the patient to the nearest hospital with appropriate facilities. In this case, the patient had sustained head trauma but no one witnessed the actual injury. It is unclear whether he fainted or had a seizure. He certainly needed continued observation in a hospital as well as a CT scan of the head at a minimum. At the time he was transferred, however, the patient was stable. He was awake and alert and not on life support. He had no open head injury, neurologic abnormality, or lateralizing signs. The patient was transported 760 miles to another facility. No documentation was provided that shows that the patient could not have received appropriate services at a closer facility accessible by ground ambulance. The submitted documentation does not demonstrate that this patient had an exceptional circumstance that required immediate and rapid ambulance transport that could not have been provided by land ambulance.
Appeal type: Urgent Care
Decision: Upheld

A 60-year-old female enrollee has requested an emergency room visit for the treatment of her vomiting and nausea. Findings:  The physician reviewer found that an emergency is defined as the sudden onset of symptoms of such severity that a prudent layperson would believe lack of immediate medical attention would seriously endanger her health. This patient reported diarrhea on the day of her visit, but her other symptoms of dizziness and weakness had been present for one week. Further, she had already been evaluated for those symptoms the day prior. Since the patients symptoms were not acute in onset, and she denied any life-threatening symptoms such as chest pain or shortness of breath, her symptoms do not meet criteria for an emergency.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Radicava for treatment of the enrollees amyotrophic lateral sclerosis (ALS). Findings:  The physician reviewer found that in May 2017, Radicava was approved by the U.S. Food and Drug Administration (FDA) to treat patients with ALS. Radicava showed efficacy in a small subset of patients with ALS who met criteria identified in post-hoc analysis of a previous phase 3 study, showing a significantly smaller decline of ALSFRS-R score compared with placebo. Currently, there are no other therapies available similar to this medication for the treatment of ALS. Accordingly, the requested Radicava is 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 medication is 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: Reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for immune globulin therapy for treatment of diabetic amyotrophy. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services in this clinical setting.  There is a lack of evidence demonstrating that intravenous immune globulin is effective in treating diabetic neuropathy, lumbosacral plexopathy or the pain associated with these conditions.  The evidence of efficacy of intravenous immune globulin has been found in small studies without adequate controls. Intravenous immune globulin, from a neurologic perspective, is indicated for the treatment of chronic demyelinating inflammatory neuropathy, for which there is no evidence in this case.  The elevation of the spinal fluid protein is a nonspecific finding seen disproportionally in diabetics and is not specific for the diagnosis of chronic demyelinating inflammatory neuropathy.  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 neurology 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 36-year-old male enrollee requested authorization and coverage of a chest CT scan. The Health Plan denied the request indicating that the requested chest CT scan is not medically necessary for the evaluation of the enrollees risk of heart disease.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plans denial on the basis that the requested CT scan is medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

A female enrollee requested for the pulse stimulation (P-Stim) treatment device for medical treatment of her post-operative back pain. Findings:  The physician reviewer found that there is a lack of medical literature to support its use in failed back surgery syndrome, post laminectomy syndrome or lumbar neuroma pain. This patients records do not document that she has undergone regular auricular acupuncture to determine effectiveness. Also, there is no documentation that she has received any psychological treatment for her condition, which has been shown to be beneficial (Hussain and Erdek). Therefore, the use of P-Stim is not medically necessary for the treatment of this patients failed back surgery syndrome, post laminectomy syndrome or lumbar neuroma pain.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for Linzess. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the patients medical condition. The submitted documentation supports the medical necessity of the requested medication. In placebo-controlled Phase III clinical trials, Linzess is indicated to restore colonic function in chronic constipation, and is U.S. Food and Drug Administration-approved for chronic constipation. Researchers found Linzess has a mechanism of action that differs from osmotic laxatives and stimulant laxatives, and can be effective even if those patients who have failed traditional treatment with laxatives and stimulant laxatives. In multicenter, randomized, blinded, placebo-controlled Phase III clinical trials, Linzess significantly increased weekly spontaneous bowel movements, while reducing abdominal pain in patients with chronic constipation. The American Gastroenterological Association Medical Position Statement on Constipation states that the first line of therapy should be an osmotic agent, and then another type of laxative such as a stimulant laxative should be tried, followed by a newer agent, such as Linzess. The patients imaging studies did not show obstruction in this case, but did show ongoing constipation over a long period of time. For these reasons, Linzess 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

A 51-year-old female enrollee requested authorization and coverage of the medication Fosamax. The Health Plan denied the request indicating that the requested medication is not medically necessary for the treatment of the enrollees osteoporosis.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.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a computed tomography (CT) colonography. Robertson and colleagues note, Given the high positive predictive value of fecal immunochemical test (FIT) for cancer detection, colonoscopy is recommended when the test is positive, not repeat FIT. The authors further note, Colonoscopy is the one structural examination that both directly evaluates the entire colorectal mucosa and affords the opportunity to simultaneously remove significant neoplasia. Given these characteristics, it is the optimal test to follow up on a positive screen. In this case, the records show that difficulty with bowel preparation for both colonoscopy and CT colonography has been the obstacle to screening, rather than a direct contraindication to the colonoscopy procedure itself. Gu and colleagues note that there are currently multiple low-volume bowel preparations available. Given that the records do not document a contraindication to the colonoscopy procedure itself, and as current medical literature supports the use of a colonoscopy rather than CT colonography in patients with a positive FIT, the requested service is not medically indicated. Therefore, CT colonography is not medically necessary for the evaluation of this patient.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 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

A 36-year-old female enrollee has requested Subutex for the treatment of depression.  Findings:  The physician reviewer found that Subutex is not FDA approved or commonly used for treatment of depression. The short and long term effects of Subutex in patients with depression are not known. There are no double blind studies to support the efficacy of Subutex in depression.  Subutex is not the standard of care in the treatment of depression.
Appeal type: Medical Necessity
Decision: Overturned

A male enrollee requested acute inpatient psychiatric hospitalization services for medical treatment of his behavioral health conditions.  Findings:  The physician reviewer found that based on the documentation provided, the inpatient services were medically necessary initially, and discharge to a less restrictive setting would have been appropriate shortly thereafter.  Initially, it was reported that the patient was withdrawn and likely responding to internal stimuli.  Shortly thereafter, the patient was making some improvements; had a family meeting, and he had no physical complaints.    He reported feeling better, and his antipsychotic medication had not changed recently.  There was no evidence of an acute psychiatric syndrome.  Thus, acute inpatient psychiatric hospitalization services were medically necessary initially for the patients medical condition, but not thereafter.
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:  Three physician reviewers found that the breast tomosynthesis at issue was likely to be more beneficial for evaluation of the patients medical condition than available standard modalities. The medical literature investigated the effect of integrated two-dimensional (2D) and three-dimensional (3D) mammography in the breast cancer screening population. The authors found that Integrated 2D and 3D mammography improves breast cancer detection and has the potential to reduce false positive recalls.  Thus, there is support in the medical literature for the use of breast tomosynthesis over conventional mammogram due to improved cancer detection rate. Based on the support in the medical literature and the clinical documentation submitted for review, the use of breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.  Final Result: Three 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 authorization and coverage for Opsumit. Opsumit is a dual endothelin receptor antagonist indicated for the treatment of World Health Organization (WHO) group I pulmonary artery hypertension (PAH) in patients with class II-III NYHA symptoms. WHO group I patients include those with idiopathic PAH, heritable PAH, PAH caused by connective tissue disorders and PAH caused by congenital heart disease with repaired shunts. Per Pudillo and colleagues, Opsumit has been studied only in patients with WHO group I PAH. Based on the records, the patient does not have documented WHO group I PAH and more likely has WHO group 4 PAH as a result of thromboembolic disease with documented prior pulmonary embolism. Current medical evidence does not support the use of Opsumit in this clinical setting. Therefore, Opsumit is not medically necessary for this patient.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 internal medicine with a subspecialty certificate in cardiovascular disease, 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 38-year-old female enrollee requested authorization and coverage for removal of an occiptal mass performed on an inpatient basis. The Health Plan has denied this request indicating that it is not medically necessary for the occiptal mass to be removed on an inpatient basis.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer upheld the Health Plans denial on the basis that the requested service is not medically necessary.
Appeal type: Urgent Care
Decision: Overturned

A 60-year-old male enrollee has requested emergency services for the treatment of his medical condition. Findings:  The physician reviewer found that at issue in this case is whether a prudent layperson in the patients circumstances would believe he was experiencing an emergency medical condition. 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. Review of the submitted clinical evidence demonstrates that this patient complained of swelling and pain in the neck as well as in his left ear. No diagnostic testing was performed although these symptoms could reasonably have engendered a cardiac work-up to include an electrocardiogram, chest x-ray, complete blood count, chemistry panel, and Troponin levels. The treating provider did not quantify the severity of the patients neck pain or order diagnostic tests. As such, the patients diagnosis of superior vena cava syndrome was not discovered at that time. However, this does not negate the fact that the patient had a bona fide emergency at the time of his presentation to the ED. Superior vena cava syndrome commonly occurs with lung cancer. A tumor in the chest or swollen lymph nodes can press on the superior vena cava, blocking the blood flow, and thus cause symptoms that would lead a prudent layperson to seek immediate medical attention. All told, the patient had an emergency medical condition and needed to be seen in the ED. The patients final diagnoses are life-threatening medical problems and a prudent layperson would have reasonably believed his life to be in peril without immediate medical attention.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a consultation/office visit with a nephrologist.  The submitted documentation fails to demonstrate the medical necessity of the requested services. This patient has chronic abdominal pain. An incidental adrenal mass was discovered during CT imaging.  An adrenal incidentaloma is a mass lesion greater than 1 cm in diameter, discovered accidentally during radiologic examination. For a patient with an adrenal incidentaloma that is 2.4 cm, they should be evaluated for the possibility of malignancy and subclinical hormonal hyperfunction.  A referral to an endocrinologist is an appropriate first step to the evaluation. In this case, the documentation does not support that the patient has any underlying kidney disease or dysfunction. Thus, the requested consultation/office visit with a nephrologist is not medically necessary 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 internal medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 57-year-old female enrollee has requested Avastin (J9035  Injection bevacizumab, 10 mg) for treatment of her metastatic adenocarcinoma.  Findings:  Three physician reviewers found that a review of the clinical data suggests that Avastin has been approved for use in certain cancers including non-small cell lung cancer, clear cell renal cancer, colon cancer, brain tumors, and ovarian cancer. The published guidelines from the National Comprehensive Cancer Network (NCCN) recommend the use of Avastin to be restricted, even in treating these specific cancers, to well selected patients and treatment regimens. Clearly, Avastin is not a drug believed to have such widespread efficacy that it has a role in the treatment of all cancers as delineated by the NCCN guidelines and the manufacturers of the medication. The use of Avastin in this clinical situation is not likely to provide this patient with equivalent or superior results as compared to standard, proven therapies for her cancer.