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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for the pneumococcal conjugate vaccine PCV 13 for treatment of the enrollees post-procedural hypothyroidism. Findings:  The physician reviewer found that in this case, the patient does not meet any of the Centers for Disease Control and Prevention (CDC) and Advisory Committee on Immunization Practices (ACIP) recommended indications for pneumococcal conjugate vaccine. This criteria include patients with immunocompetent disorders such as cerebrospinal fluid (CSF) leak, cochlear implant, 65 years of age or older, or asplenia. As such, the request for pneumococcal conjugate vaccine PCV 13 is not medically necessary for treatment of this patients medical condition. 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 internal medicine with sub-specialty certifications in allergy and immunology and 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 a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 42-year-old female enrollee requested authorization and coverage of five months of Bicillin therapy. The Health Plan  denied the request indicating that the requested therapy is considered experimental for treatment of the enrollees Lyme disease.Three physician reviewers performed an experimental/investigational Independent Medical Review. All three physician reviewers concluded that the requested therapy is not likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy. Because all three physician reviewers concluded that the requested therapy is not likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy, the Health Plans denial has been upheld.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for a second round of fertility preservation services. As part of education and informed consent prior to cancer therapy, oophorectomy, or any procedure that may jeopardize a womans ability to conceive in the future, health care providers should address the possibility of infertility. fertility preservation options exist for both female and male prepubertal and pubertal patients, and discussion of such options with patients and their families prior to the initiation of therapy and/or before further deterioration of gonadal function is crucial. In this case, the patient is status post left oophorectomy and requires surgery on the remaining ovary due to a large dermoid cyst. A prior egg retrieval procedure did not yield the recommended eight to ten oocytes. Given that upcoming surgery may jeopardize the patients ability to have biological children, the requested services are medically indicated. Therefore, a second round of fertility preservation services are 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 obstetrics and gynecology with sub-specialty certification in reproductive endocrinology and infertility and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient was diagnosed with alcohol use disorder, alcohol withdrawal syndrome, and transaminitis. Patient was discharged from a chemical dependency detoxification unit and admitted for residential treatment. The patient had requested reimbursement for residential treatment center (RTC). The Health Plan denied the request and reported the services were not medically necessary for the treatment of this patient. At issue in this case is whether RTC services were medically necessary for treatment of the patients medical condition. The patient was admitted to a RTC with a history of alcohol use with associated mood symptoms due to substance use. He denied a history of suicidal ideation or suicide attempts and denied inpatient psychiatric treatment. The patient did not exhibit acute withdrawal symptoms during RTC treatment. The patient did not report any significant medical issues. The patient did not have a plan or intent of self-harm and did not engage in any self-harm behaviors during treatment. No aberrant behavior was noted during his RTC admission. Medical literature shows, continued stay and discharge of patients with addiction and co-occurring conditions. For acute intoxication and/or withdrawal potential, the patients score is 0. For biomedical condition and complications, the patients score is 0. According to the ASAM criteria, all six dimensions must be met for placement in the RTC level of care. The patients presentation did not meet the required six out of six dimension criteria. The medical evidence does not support the services at issue in this clinical setting. Therefore, RTC services were not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested services were 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 and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The patients parent has requested authorization and coverage for 36 vision therapy sessions. The American Optometric Association (AOA) states that, studies suggest that vision therapy is effective in altering accommodation, with a resultant change in amplitude and facility and a decrease in symptoms. Studies have demonstrated that vergence therapy improves vergence ability, and that the effects persist over time. Saccadic training has been shown to help with early reading fluency and is an effective treatment over a period of six weeks. The AOA clinical practice guideline supports treatment with up to 20 visits. This patient was diagnosed with general binocular dysfunction, oculomotor dysfunction of pursuits and saccades, and accommodative dysfunction. The patients results on the Eye Optics Optometry Center supports an indication for the requested vision therapy. Given these findings, 20 vision therapy services are medically necessary for treatment of this patient. Final Result: The reviewer determined that a portion of the requested services is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned. Credentials/Qualifications: The reviewer is board certified in optometry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for a bilateral mastectomy. Chest surgery in transgender male minors is a common treatment for gender dysphoria. The World Professional Association for Transgender Health (WPATH) states, Chest surgery in female-to-male patients could be carried out earlier, preferably after ample time of living in the desired gender role and after one year of testosterone treatment. Researchers reported that chest surgery in transgender male minors was a safe and effective treatment for gender dysphoria, noting, Chest dysphoria was high among presurgical transmasculine youth, and surgical intervention positively affected both minors and young adults. Given these findings, professional guidelines and clinical practice should consider patients for chest surgery based on individual need rather than chronologic age. In this case, the patient has gender dysphoria and has spent ample time living in the desired gender role and has begun testosterone treatment. The patients provider reports that the requested service is medically indicated for the treatment of this patient. Therefore, a bilateral mastectomy is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested service is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in psychiatry with expertise in transgender health and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a whole body bone scan for evaluation of the enrollees bilateral foot pain.  Findings:  The physician reviewer found that the patients provided records fail to meet the standard criteria for a bone scan.  Prior to ordering a bone scan, the standard practice is that a patient must be suspected of having a stress fracture due to overuse or excessive activity, have localized pain, have symptoms that persist despite rest and have normal x-rays obtained on two separate occasions separated by at least three weeks prior to ordering a bone scan. Typically, a second set of x-rays is obtained after three to four weeks to determine if bone healing is present.  If the second set of x-rays is negative, then a bone scan would be a reasonable test to rule out a stress fracture. However, in this case, the provided records do not support that these criteria have been met by this patient. Final Result: The reviewer determined that the requested services are not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: The physician 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: Experimental/Investigational
Decision: Upheld

The parent of an 11-year-old male enrollee has requested  coverage for vision therapy for treatment of the enrollees multiple medical conditions.  Findings:  Two physician reviewers found that the efficacy of vision therapy in the treatment of dyslexia and learning disabilities is not supported by the peer-reviewed medical literature. Although studies support that visual/ocular defects are more prevalent in patients with learning disabilities, it is higher brain function that is responsible for the decoding of retinal images (American Academy of Ophthalmology, 1998). There is a great deal of controversy surrounding the extent to which visual problems are responsible for dyslexia. The available peer-reviewed medical literature indicates that the role of eye movements and visual perception are not critical factors in the reading impairment found in dyslexia (American Academy of Ophthalmology, 2007) and it continues to remain unclear whether visual deficits in children are linked to reading or learning difficulties (Barrett). In sum, there is inadequate scientific literature supporting the use of vision therapy in the treatment of learning disorders. Therefore, the denial was appropriate.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for corneal optical coherence tomography.Findings:  Three physician reviewers found that Descemet membrane endothelial keratoplasty is a partial thickness cornea transplant where the host Descemet membrane and endothelium are replaced by donor Descemet membrane and endothelium. Given the delicate nature of the transplanted tissue and postoperative edema, it may be difficult to assess the position of the graft tissue. Anterior segment optical coherence tomography is beneficial in the postoperative care in this setting, as it helps to visualize the graft tissue in relationship to the host cornea. Optical coherence tomography can confirm the position of the graft in relationship to host stroma. This imaging modality can assist in cases of significantly edematous stroma, which may indicate the graft is not functioning well or is upside down. In sum, corneal optical coherence tomography was likely to have been of greater benefit than other methods of evaluating this patient. Final Result: The reviewers determined that the services at issue were likely to have been more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in ophthalmology 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: Experimental/Investigational
Decision: Upheld

A 73-year-old female enrollee has requested an MRI of the breast for an evaluation of her nipple discharge. Findings:  Two physician reviewers found that this patient does not meet the high-risk group of patients in whom breast MRI has shown to provide a benefit. There is no known BRCA1 or BRCA2 mutation and no personal history of breast cancer by age 50. There is no history of ovarian cancer. The patient does not have a history of three or more affected first-degree or second-degree relatives. Additionally, there is no documentation of chest wall irradiation prior to the age of 30. There are no other criteria that would place this patient with a greater than 20% lifetime risk of developing breast cancer. Nor is there peer-reviewed evidence supporting the use of breast MRI for this particular indication of bloody nipple discharge. Surgical excision of the abnormal duct would be considered standard treatment in this setting. The medical literature does not support the superior efficacy of breast MRI for surgical planning in this clinical situation. The use of MRI as a surgical planning tool is not likely to provide added clinical value in this setting.
Appeal type: Medical Necessity
Decision: Upheld

A 47-year-old female has requested an MRI of the right shoulder for an evaluation of her shoulder problem. Findings:  The physician reviewer found that this patient has numerous medical problems, including muscular pain. Review of the submitted clinical evidence reveals no documentation of recent evaluation of her neck and right upper extremity pain. There is no evidence of recent radiographs of the right shoulder in the records provided. As this patient has no documented recent physician concern of a rotator cuff abnormality or labral abnormality, there is a lack of medical evidence to support an MRI of the right shoulder. The patient does not meet clinical indications for an MRI of the shoulder at this time.
Appeal type: Experimental/Investigational
Decision: Overturned

The mother of a 15-year-old female enrollee has requested a continuous glucose monitoring system (CGM) for the treatment of the enrollees diabetes. Findings:  Two physician reviewers found that this patient already monitors her blood sugars at an increased frequency of 10-12 times daily.  However, this is still leaving unattended gaps of unpredictable blood glucose excursions that disturb her quality of life and performance and increase her chances of developing diabetes-related complications.  The FDA has approved the system in dispute for children as young as age seven.  The medical literature supports the value of real-time glucose monitoring in improving diabetic control in both adults and children.  A CGM will allow this brittle patient to ultimately improve her blood glucose values and HgbA1c.  More importantly, CGM will increase her chances for preventing and surviving unpredictable or asymptomatic hypoglycemic events.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for bronchial thermoplasty. Findings:  Three physician reviewers found that the records fail to demonstrate the superior effectiveness of the requested services.  In this case, the pulmonary function tests are not diagnostic of obstructive lung disease alone and show a mixed pattern with restriction on spirometry with evidence of hyperinflation. The bronchodilator response does not show improvement in forced expiratory volume 1 (FEV1) alone, but instead both the FEV1 and forced vital capacity (FVC) increase proportionately. Most concerning is the low diffusing capacity of the lungs for carbon monoxide (DLCO), which is not characteristic of asthma alone and may represent other alveolar processes, such as chronic fixed airways obstruction. There is a lack of history provided prior to 2015 detailing the patients asthma history, medication use, symptoms, steroid use and frequency of exacerbations, which are important in determining if patient is a candidate for bronchial thermoplasty. This patient has numerous other comorbidities which may explain the persistent symptoms, including morbid obesity, obstructive sleep apnea, diabetes and chronic sinusitis.  The severity of the obesity is concerning and may play a significant role in patient symptomology. Additionally, the presence of tracheobronchopathia osteochondroplastica (TBOP) with mild obstruction of lower lobe and middle lobe airways and history of recurrent pneumonias is likely to be a relative contraindication to bronchial thermoplasty.  The medical evidence does not support the requested services in this clinical setting.  In sum, the requested bronchial thermoplasty is not likely to be of greater benefit than other treatment options. Final Result: 2 of 3 reviewers determined that the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: All three physician reviewers are board certified in internal medicine with sub-specialty certification in pulmonary disease 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: The parent of an enrollee has requested authorization and coverage for Norditropin FlexPro 15 mg/1.5 mL. This patient has evidence of growth hormone deficiency based on a history of poor growth velocity and a height which was 2.2 standard deviation below the mean prior to therapy. There is evidence of growth hormone deficiency based on failed stimulation tests with two agents. The records document good response to growth hormone therapy based on the growth chart provided. The patient has open epiphyses. The medical evidence supports growth hormone therapy in this clinical setting. Therefore, Norditropin FlexPro 15 mg/1.5 mL 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 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: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for speech and sign language therapy services for treatment of the autism and language delay. Findings:  The physician reviewer found that the request for speech and sign language therapy has not been established as medically necessary for treatment of the patients medical condition. According to the documentation submitted for review, the patient has been treated with more than two years of speech therapy, however he has not made any significant improvement in his functional communicative skills. The patient has not retained learned signing. The patients lack of retention does not support continued speech and sign language therapy. 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 child 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

The patient has requested reimbursement for residential treatment center (RTC) services. The American Association of Community Psychiatrists Level of Care Utilization System (LOCUS) provides a reliable framework for determining the appropriate level of care for adults needing mental health treatment. Using LOCUS, providers score patients on a scale of 1-5 using a six-pronged Dimensional Rating System. The six dimensions include: (1) risk of harm; (2) functional status; (3) medical, addictive and psychiatric comorbidity; (4) recovery environment (a. stressors and b. supports); (5) treatment and recovery history; and (6) engagement. The composite score is then used to determine the level of care needed. Based on LOCUS criteria, this patient met the criteria for RTC treatment. The patient has a composite score which is consistent with medically monitored residence based services, such as RTC. Given these findings, the RTC services were medically necessary 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 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.