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

The patient is a 41-year-old female with a diagnosis of recurrent miscarriage. The record provided for review did not include prior pregnancy information or the full details of the patients previous workup. She was tested for immunologic abnormalities in August 2005. A serum NK cell assay revealed a normal percent killed NK cells and an elevated %CD19+/CD5+ level. A serum IgG for phosphoethanolamine was borderline positive. The patient was advised to undergo intravenous immunoglobulin (IVIG) therapy and had five treatments. The patients request for reimbursement was denied by the Health Plan based upon a determination that IVIG therapy was not medically necessary. The possible etiologies for the diagnosis of recurrent miscarriage are chromosomal, uterine structural, ovulatory or immunological. The treatments for immune factors, and especially their efficacy, are highly controversial. IVIG treatment for reproductive disorders and for recurrent miscarriage has been investigated in small studies for the better part of the last decade. Although a few of the studies evaluating IVIG treatment in properly characterized patients with repeated pregnancy loss showed modest benefit, others studies have shown no benefit at all. Thus, there is yet no clear efficacy    established. According to the 2004 Practice Committee Opinion of the American Society for Reproductive Medicine, IVIG treatment for recurrent miscarriage is an experimental treatment: IVIG as a treatment for recurrent pregnancy loss should be evaluated in patients who are informed, consenting participants in an institutional review board approved randomized clinical trial. For the management of recurrent spontaneous pregnancy loss IVIG therapy is an experimental treatment. There are other available therapies that are likely to be effective for patients such as this one and no indication that the standard approaches to treatment have been exhausted. Therefore, I have determined the therapy at issue was not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

A 48-year-old male enrollee, with erectile dysfunction, has requested authorization for the medication Viagra.  Findings:  The physician reviewer found that the patient has a several-year history of erectile dysfunction, which has been successfully treated with Viagra. Hyperlipidemia is documented in the patient's laboratory testing. Hyperlipidemia is a condition that is consistent with organic impotence, and in fact, appears to be included as such in the Health Plans coverage criteria. Viagra for treatment of the patients erectile dysfunction is medically appropriate and clinically indicated in this setting and should be authorized by the Health Plan.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 13-year-old male enrollee has requested an MRI for evaluation of the enrollees knee pain.  Findings:  The physician reviewer found that the submitted documentation demonstrates the medical necessity of the requested diagnostic procedure in this clinical setting.  This patient has a history of knee pain with activity.  Plain films have been negative.  His pain has persisted despite treatment with non-steroidal anti-inflammatory drugs.  Per the medical records, the possibility of internal derangement has been noted due to continued pain.  The current medical evidence supports the requested MRI in this patients case.  All told, the requested MRI is medically indicated for the evaluation of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for lumbar transforaminal epidural injection.The submitted documentation supports the medical necessity of the requested service. A systematic review and meta-analysis concluded that lumbar epidural steroid injections were effective. The authors investigated whether epidural injections of steroids produced better clinical effects than local anesthetics or saline for the treatment of lumbosacral disc herniation. Studies noted, Steroid is recommended over local anesthetics or saline for pain control in patients with lumbosacral disc herniation.  Studies noted, For lumbar disc herniation with radiculitisthe evidence is considered good for short-term and long-term relief with local anesthetics with steroids. In this case, the patient has a history of lumbar surgery, and the records document chronic back pain with radiation into the lower extremities. There is sufficient support for the requested service in this clinical setting. Therefore, the requested lumbar transforaminal epidural injection is medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested services are medically necessary to treat the patient's medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in anesthesiology, with subspecialty 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: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested skilled nursing facility (SNF) services for treatment of her medical condition.  Findings:  The physician reviewer found that there is sufficient support for the services at issue in this clinical setting.  Per the medical records, this patient had severe disability post craniotomy.  She needed recovery of speech, motor function, and ability to ambulate and was admitted to a SNF for further treatment.  Initially, it was noted that the patient was not making progress with physical therapy.  However, an adjustment in timing of medicine enabled her to cooperate and continue to achieve improvement in functionality.  Due to the intensity of treatment, she was able to achieve a good outcome.  All told, SNF services provided were medically indicated for the treatment of this patient. 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 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 64-year-old male enrollee has requested authorization for a CT angiography for evaluation of his coronary artery disease.  Findings:  Three physician reviewers found that CT angiography is not thus far a generally accepted screening or confirmatory test for the diagnosis of coronary artery disease. It is not a medically accepted replacement for conventional screening tests such as treadmill stress testing or an appropriate substitute for coronary angiography. CT angiography would not be able to accurately confirm or exclude important coronary obstruction. There is insufficient evidence supporting the use of CT angiography in the diagnosis and prognosis of coronary artery disease at this time.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for Nutropin AQ NuSpin 20 mg injector for the enrollee's short stature. Findings:  The physician reviewer found that The submitted documentation fails to demonstrate the medical necessity of the requested medication. The patients height is not less than the third percentile for age and gender, his bone age is not delayed, and his IGF-1 level is normal. He does not have known morphological abnormalities of the pituitary gland. Prior to initiation of growth hormone therapy, the patients adult height prediction was not less than 63 inches. Thus, he does not meet the U.S. Food and Drug Administration (FDA) criteria for a trial of growth hormone therapy for idiopathic short stature. The recent slowing of growth is likely to be multifactorial, and poor appetite and stimulant medication may have been contributing to the slowing of growth after discontinuation of growth hormone therapy. Furthermore, children with 22q11 deletion are known to have growth restriction, but growth hormone deficiency is not typical, and short stature associated with 22q11 deletion syndrome is not an approved indication for growth hormone treatment. Therefore, Nutropin AQ NuSpin 20 mg injector is not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medication 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 pediatrics with sub-specialty certification in pediatric endocrinology 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 patient has requested authorization and coverage for Mavyret . The submitted documentation supports the medical necessity of the requested medication regimen. all patients with chronic hepatitis C should be treated, except those with limited life expectancy due to nonliver-related conditions. The guidelines recommend that all patients should be treated, regardless of fibrosis stage.  Mavyret  is medically necessary for this patient.Final Result: The reviewer determined that the requested medication regimen 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. Findings:  The physician reviewer found that
Appeal type: Medical Necessity
Decision: Overturned

A 57-year-old female enrollee has requested laparoscopic gastric banding surgery for treatment of her obesity, hypertension, and incontinence.  Findings:  The physician reviewer found that based on review of the available records, this patient meets all standard nationally published guidelines for bariatric surgery including the National Institutes of Health (NIH) consensus guidelines for the requested surgery. She has morbid obesity with a BMI of at least 35 and serious co-morbid conditions. She has hypertension. In addition, she completed a multidisciplinary evaluation and was not determined to have any obvious medical, dietary or behavioral barriers to surgery. She has failed dietary efforts in the past and is requesting a standard primary treatment for morbid obesity. All told, the patients records support the medical necessity for the requested procedure for treatment of morbid obesity.
Appeal type: Medical Necessity
Decision: Upheld

A 34-year-old female requested authorization and coverage of the medication Actiq. The Health Plan denied the request indicating that the requested medication is not medically necessary for treatment of the enrollees back pain.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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Laparoscopic Sleeve Gastrectomy.Bariatric procedures remain a safe and effective intervention for higher-risk patients with obesity (Mechanick, J., et al.). Mechanick and associates have developed updated clinical practice guidelines for the perioperative nutrition, metabolic, and nonsurgical support of patients undergoing bariatric procedures. A team approach to perioperative care is mandatory, with special attention to nutritional and metabolic issues. These guidelines recommend that all patients should undergo a psychosocial-behavioral evaluation as well as an appropriate nutritional evaluation before any bariatric surgical procedure. In this case, the patient has been documented to have both severe obesity with a BMI of 35 kg/m2 and the co-morbid condition of hypertension. The patient is noted to have been obese and struggling with weight since childhood, and she has a long-term history of prior weight loss efforts that have not been successful in maintaining any significant weight loss. Records document that the patient has also successfully completed a standard multidisciplinary evaluation. Under these circumstances, the requested Laparoscopic Sleeve Gastrectomy is medically necessary for this patients medical condition.Final Result: The reviewer determined that the requested services are medically necessary for this patient's medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in 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: This is a female with diagnoses of seizures, Raynauds phenomenon, asthma, and systemic lupus erythematosus (SLE). The patients record reports she is allergic to methotrexate (itching) and Plaquenil (rash and tongue swelling). She was doing well and decided with the rheumatologist to wean off the use of Benlysta. However, the record reports that her lupus symptoms of fatigue, aching and malar rash slowly increased, and after ruling out an infection, the rheumatologist recommended that the patient restart Benlysta. At issue is whether the requested medication, belimumab (Benlysta) 200 mg/ml, is medically necessary to treat the patients medical condition. The treating rheumatologist documented that despite a negative antinuclear antibody test and anti-double stranded DNA test, the patient has SLE with arthritis, oral ulcers, malar rash, leucopenia, Raynauds phenomenon and positive SSB antibody testing. The patient cannot use methotrexate or Plaquenil and has received Benlysta in the past with good results. Her SLE has worsened off Benlysta, and she is requiring prednisone. The FDA labeled indication for Benlysta is as follows: Benlysta is indicated for the treatment of patients aged 5 years and older with active, autoantibody positive, SLE who are receiving standard therapy. The patients clinical picture is consistent with an SLE diagnosis. There is no evidence for active renal or central nervous system disease, where Benlysta does not work. She has received standard therapy and is on prednisone, and cannot take methotrexate or Plaquenil due to allergies. Benlysta is appropriate for this patient.  Final Result: The reviewer determined that the requested service is medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in rheumatology         and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for breast reduction surgery. The Health Plan has denied this request indicating that the requested for treatment of the enrollees bilateral symptomatic macromastia. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services. The records document evidence of symptomatic macromastia. She has neck, back and shoulder pain directly attributed to her documented macromastia. Per the American Society of Plastic Surgeons (ASPS), coverage for symptomatic breast hypertrophy should be based upon documentation of at least two symptoms regardless of body weight or weight of breast tissue removed. These symptoms include chronic breast pain due to weight of the breasts, intertrigo unresponsive to medical management, upper back, neck, and shoulder pain, unspecified backache, acquired thoracic kyphosis, shoulder grooving from bra straps, upper extremity paresthesia due to brachial plexus compression syndrome secondary to the weight of the breasts being transferred to the shoulder strap area, headache and congenital breast deformity. Based on the documentation provided, this patient does not satisfy the above criteria as supported by the ASPS, as she should have two of the above signs or symptoms, but has only been documented to have upper back, neck and shoulder pain, which is classified as one symptom. 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 plastic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Urgent Care
Decision: Overturned

A 45-year-old female enrollee has requested ambulance services for evaluation of her headache, dizziness, and nausea.  Findings:  The physician reviewer found that based upon the evidence provided, a prudent layperson would have sought ambulances services in this situation. The patient had severe pain, headache, nausea and dizziness of acute onset. The symptoms were of sufficient severity, including severe pain, such that the absence of immediate medical attention could reasonably be expected to result in placing the patients health in serious jeopardy; serious impairment to bodily functions; and serious dysfunction of any bodily organ or part. A prudent layperson would have thought this to be an emergency medical condition and would have sought ambulance services for immediate medical attention. For the reasons set forth above, the patients symptoms met prudent layperson criteria for the ambulance services.
Appeal type: Experimental/Investigational
Decision: Upheld

A 67-year-old female enrollee has requested brain DaT (SPECT) scan for evaluation of her hemifacial spasm.  Findings:  Three physician reviewers found the services at issue were not likely to have been more efficacious than other methods of evaluation.  The diagnosis of parkinsonism or Parkinsons disease is a clinical determination.  It is not standard of care to utilize a DaT scan to make this diagnosis.  A DaT scan may be beneficial when it is not clear whether a patient has an essential tremor or Parkinsons disease.  However, this was not the clinical scenario in this case.  Therefore, the brain DaT (SPECT) scan is not likely to have been of greater benefit than traditional diagnostic and clinical examination procedures.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 53-year-old male with moderate to severe atrophy of the maxillary anterior ridge and well pneumotized maxillary sinuses. He is currently wearing a maxillary full denture. Records do not indicate any history of malnutrition. Dental records from October 2004 indicate an obese patient wearing a full upper denture with fair retention and a partial lower denture. The patients treatment plan is for bone grafting to allow placement of dental implants for improved retention of his denture.The requested procedure is dental in nature and will provide improved retention of a maxillary denture. However, the patient does not have a medical condition that has resulted from the wearing of a full maxillary denture for 37 years. As stated above submitted records provide no evidence of malnutrition with fair retention of the upper denture. Therefore, based upon the records provided, there is no evidence the requested procedure is medically necessary. As such, the Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Botox for treatment of her migraines. Two physician reviewers found that this patient has chronic migraine as defined by the International Classification of Headache Disorders III per the description of the treating neurologist who is a headache specialist. In addition, the patient has tried and failed three different classes of migraine preventive therapies. As this patient does have chronic migraine by definition, and meets the criteria for use, the requested Botox is more likely to be beneficial than standard therapy. Final Result: Two 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: One reviewer is board certified in anesthesiology with sub-specialty certification in pain medicine and is actively practicing.  Two reviewers are board certified in neurology 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: An enrollee has requested magnetic resonance imaging (MRI) of the lumbar spine for evaluation of the enrollees back pain. Findings: The physician reviewer found that although this patient does not have a neurological deficit, the extent and nature of his T12 vertebral fracture cannot be gleaned from the x-ray report. The American College of Radiology (ACR) recommends advanced imaging with MRI when a compression fracture interferes with activities of daily living activities such as detailed for this patient. The rationale is to determine the extent of the fracture, assess the posterior elements for displacement, and determine the extent of canal encroachment. The best exam for this determination is the requested MRI of the lumbar spine. The patient does not exhibit point tenderness over the dorsal spine and the T12 vertebral body will be included in the field of view of the lumbar spine. Thus, the requested MRI of the lumbar spine is supported as medically necessary for further evaluation of this patients T12 vertebral compression fracture.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.